NUR 200 Case Study
Save
Terms in this set (18)
Data is normal, abnormal or has changed.
Identifying signs and
Subj
symptoms (Noticing)
Obj
Data from all available sources.
Pt-interview and assessment
Gathering complet and emr-health hx and dx
accurate data (Noticing) meds-MAR/TAR
spouse/cg-interview, when
labs, dx reports, etc
Systemic method or assessment
Assessing Systematically 1. Head-to-toe
and Comprehensively 2. pain assessment
(Noticing) 3. focused assessment
4. disease process
When a situation has risks of complications
Predicting (and managing)
1. NPO-dehydrate
potential complications
2. wound/incision-infection
(noticing)
3. immobility-DVT
Arriving at a conclusion without evidence.
Identifying Assumptions
1. non-compliance
(Noticing)
2. dementia
, Grouping together information with a common theme
to determine issues, problems, or concerns.
1. Physical: LOC, CNS, GI, vision
Clustering related
2. Meds: treatment/adverse
information (Interpreting)
3. Medical hx: current Dc
4. Physiological : Widow, work hx, support
5. Dx tests: MRI, CT, 12 lead EKG, etc
Data doesn't match may indicate add'l problems
Recognizing 1. Movement sufficient when states has sever pain but
inconsistencies grimacing; states no pain
(interpreting) 2. c/o nausea but requesting pizza to eat
3. laughing excessively but states is sad
Actions based on inaccurate or unreliable info could
cause pt harm
1. Recheck VS if finds abnormal readings
Checking accuracy and
2. Reassess pain level measurement by using numeric
reliability (interpreting)
scale or Wong-Baker
3. Redo lab associated with pt s/sx
4. Verifying HCP orders
Recognizing info that is pertinent to a particular
problem depend on situation at hand.
Distinguishing relevant Relevant: Unsteady gait r/t fall; raised temp r't
from irrelevant infection; a-fib r/t irregular pulse; medial hx-DM,
(interpreting) hgA1c results, HTN, incr BP
Irrelevant: Hobbies, hysterectomy 25 yrs ago, works at
IHOP
Determine importance or significance of pt info to
current situation.
Determining the
Determining "clinical noise" myriad of info that
importance of info
changes thru the day *recent, sudden or significant
(interpreting)
change-unexpected prig, fired from job, new living
situation going on vacay
Save
Terms in this set (18)
Data is normal, abnormal or has changed.
Identifying signs and
Subj
symptoms (Noticing)
Obj
Data from all available sources.
Pt-interview and assessment
Gathering complet and emr-health hx and dx
accurate data (Noticing) meds-MAR/TAR
spouse/cg-interview, when
labs, dx reports, etc
Systemic method or assessment
Assessing Systematically 1. Head-to-toe
and Comprehensively 2. pain assessment
(Noticing) 3. focused assessment
4. disease process
When a situation has risks of complications
Predicting (and managing)
1. NPO-dehydrate
potential complications
2. wound/incision-infection
(noticing)
3. immobility-DVT
Arriving at a conclusion without evidence.
Identifying Assumptions
1. non-compliance
(Noticing)
2. dementia
, Grouping together information with a common theme
to determine issues, problems, or concerns.
1. Physical: LOC, CNS, GI, vision
Clustering related
2. Meds: treatment/adverse
information (Interpreting)
3. Medical hx: current Dc
4. Physiological : Widow, work hx, support
5. Dx tests: MRI, CT, 12 lead EKG, etc
Data doesn't match may indicate add'l problems
Recognizing 1. Movement sufficient when states has sever pain but
inconsistencies grimacing; states no pain
(interpreting) 2. c/o nausea but requesting pizza to eat
3. laughing excessively but states is sad
Actions based on inaccurate or unreliable info could
cause pt harm
1. Recheck VS if finds abnormal readings
Checking accuracy and
2. Reassess pain level measurement by using numeric
reliability (interpreting)
scale or Wong-Baker
3. Redo lab associated with pt s/sx
4. Verifying HCP orders
Recognizing info that is pertinent to a particular
problem depend on situation at hand.
Distinguishing relevant Relevant: Unsteady gait r/t fall; raised temp r't
from irrelevant infection; a-fib r/t irregular pulse; medial hx-DM,
(interpreting) hgA1c results, HTN, incr BP
Irrelevant: Hobbies, hysterectomy 25 yrs ago, works at
IHOP
Determine importance or significance of pt info to
current situation.
Determining the
Determining "clinical noise" myriad of info that
importance of info
changes thru the day *recent, sudden or significant
(interpreting)
change-unexpected prig, fired from job, new living
situation going on vacay
