What does assessment mean? - Answers collection of data about an individual's health state
Subjective data - Answers what the subject says about themselves during assessment
Objective Data - Answers what you sense during assessment process
see, hear, smell, feel
Database - Answers entire patient's file, including lab studies
Diagnostic reasoning: - Answers analyzing all data and drawing conclusions to identify diagnosis
First-Level Priority - Answers emergent, life threatening
ABC's
airway
breathing
circulation
second-level priority - Answers needs attention before it becomes a first level
examples of second level priorities - Answers mental status change
acute pain
infection risk
abnormal labs
safety risks
third-level priorities - Answers important, but can be helped after first and second levels are cleared
Third-level priority problems - Answers knowledge deficit, mobility issues, family coping
complete database - Answers complete health history and full physical examination. done in primary
care settings
includes minor things like wisdom teeth removal at early age
focused (problem-centered) database - Answers collect a targeted history and physical examination
around area of concern. completed in all settings
follow-up database - Answers used to check status of known issue to verify if change has occured
completed in all settings
emergency database - Answers urgent, rapid collection of info in conjunction with life-saving
measures. complete database can follow once patient is stable
culture - Answers includes attitudes, values, beliefs, norms, and roles
culture is - Answers learned from birth
shared by all group members
adapted to environmental factors
always changing
sub-cultures may share different beliefs, values, attitudes, norms
socialization - Answers raised within a culture and acquiring the norms, values
ethnicity - Answers social group that may share traits - geographic origin, religion, language, values,
traditions
acculturation - Answers adopting culture and behaviors of the major culture
biomedical/scientific beliefs - Answers all events have cause/effect
bacteria & viruses cause diseases
basis for most medical profession education
, germ theory - Answers bacteria & viruses cause diseases
naturalistic - Answers forces of nature must be kept in balance/harmony
asians: yin/yang
hispanic/arab/asian: hot cold theory
magicoreligious - Answers supernatural forces dominate
everyone's fate is up to supernatural forces - good and evil
traditional treatments for hispanics - Answers rely on curadernos/as, espiritualista, yerbos/as,
parteras
traditional treatments for african - Answers houngan, spiritualist
traditional treatments for american indian - Answers shamans
traditional treatment for asians - Answers herbalist, acupuncturist, bonesetters
traditional amish treatments - Answers brauchers
pain is - Answers embedded in cultural context
may be found objectively
cultural self-assessment - Answers always the first step, as a nurse, leave beliefs at home
cultural assessment - Answers must always ask about cultural practices that may impact care
what if patients have a preferred language - Answers check hospital to see what services they offer.
family/friends are not sufficient translators
spiritual assessment - Answers FICA
F:aith
I:mportance/influence
C:ommunity
A:ddress/action
How should you address patients? - Answers by last name unless directed otherwise
What should you do to introduce interview? - Answers state who u are and purpose/plan
open-ended questions - Answers questions that allow respondents to answer however they want
closed/direct question - Answers yes or no, few words
specific info and shorter
nonverbal skills - Answers physical appearance, posture, gestures, facial expression, eye contact,
voice, touch
traps of interviewing - Answers - Providing False Reassurance
- Giving Unwanted Advice
- Using Authority
- Using Avoidance Language
- Engaging in Distancing
- Using Profession Jargon
- Using Leading or Biased Questions
- Talking too much
- Interrupting
- Using "why" Questions
Interviewing people with special needs - Answers Hearing impaired
Acutely ill
Under influence of street drugs or alcohol
Those who must be asked personal questions
Sexually aggressive
Crying
Angry and threatening violence
Anxious
SBAR Situation - Answers What is the situation you are calling about?
• Identify self, unit, patient, room number.
• Briefly state the problem, what is it, when it happened or started, and how severe.