NUR 200 Study Resources | Nursing Exam Prep, Case Studies & Practice Guides

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Identifying signs and symptoms (Noticing)


Data is normal, abnormal or has changed.
Subj Image
Obj




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Gathering complet and accurate data (Noticing)


Data from all available sources.
Pt-interview and assessment Image
emr-health hx and dx
meds-MAR/TAR
spouse/cg-interview, when
labs, dx reports, etc




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Assessing Systematically and Comprehensively (Noticing)


Systemic method or assessment
1. Head-to-toe Image
2. pain assessment
3. focused assessment
4. disease process

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Predicting (and managing) potential complications (noticing)


When a situation has risks of complications
1. NPO-dehydrate Image
2. wound/incision-infection
3. immobility-DVT




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Identifying Assumptions (Noticing)


Arriving at a conclusion without evidence.
1. non-compliance Image
2. dementia




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Clustering related information (Interpreting)


Grouping together information with a common theme to determine issues, problems, or concerns.
1. Physical: LOC, CNS, GI, vision Image
2. Meds: treatment/adverse
3. Medical hx: current Dc
4. Physiological : Widow, work hx, support
5. Dx tests: MRI, CT, 12 lead EKG, etc




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