Who spends the most time with the client, knows the most about the client, and is able to communicate the client's needs to the rest of the health care team the most effectively?
What are the 3 areas of assessment the nurse focuses on in order to get a complete picture of the client?
Body: assess the physical systems
Mind: assess psychosocial health
Spirit: assess for religious or spiritual beliefs
What is the nursing process?
- Assess: gather data
- Diagnosis: client problems that are based on medical diagnosis
- Plan: goals
- Implement: interventions
- Evaluate: how the client responded to the intervention
The nursing process is not linear. The nurse will jump back and forth between the steps depending on additional data acquired about the client.
What are clinical judgment skills?
Clinical judgment skills are:
- understanding WHY an intervention is done
- prioritizing what is important
- interpreting sign and symptom data
- gathering more information if there is not enough to make an informed decision
When does teaching and discharge planning by the nurse begin with a client?
Teaching and discharge planning can begin during the assessment even while the client is being admitted.
During the admission assessment data is gathered by the nurse such as home environment and available resources, so teaching can begin right away if there are needs.
What are the 2 purposes of doing an assessment on a client?
The purpose of doing an assessment is to:
- gather data (especially abnormal data) about the client to heal the client or prevent them from getting sick.
- notify the health care provider (HCP) of immediate complications or changes in the client's condition in order to update the care plan.
The HCP can be a doctor, nurse practitioner or physician assistant.
What is the typical assessment order for most systems?
The typical assessment order is:
What is the difference between a focused assessment and a comprehensive assessment?
- A focused assessment focuses on the immediate concern and is done when the client has a specific complaint or immediate information is needed.
- A comprehensive assessment is when the nurse assesses the entire client head to toe.
Which main physical systems are assessed in a comprehensive assessment starting from head to toe?
The main systems assessed are:
In addition to the physical assessment of the client, what additional data does the nurse look at to get an overall picture of the client?
To get an overall picture of the client, look at:
- CBC, BMP or CMP
- labs specific to problem
imaging diagnostic tests
- x-rays, CT scan, MRI, etc
- medical and surgical history and physical from HCP
- medication record
How often should a typical physical assessment be done on each of the following units:
- Progressive or Step-down unit
- Medical-surgical unit
Post-Op: focused assessments every 5- 15 minutes
ICU: about every 1-2 hours
Progressive or Step-down unit: about every 2-4 hours
Medical-surgical floor: about every 4-8 hours
What is subjective and objective data?
Subjective data is what the client tells you
- example: the client's stated pain level
Objective data is what anyone can observe
- example: a set of vital signs
Posterior and Anterior
Posterior means the back of something
Anterior means the front of something
Distal and Proximal
Distal means away from something
Proximal means closer to something
What is a very quick and basic neuro assessment?
Assess the level of consciousness by asking the client 4 questions:
- Person: What is your name?
- Place: Where are you?
- Time: What year is it? or Who is the president?
- Situation: Do you remember why you are here?
What is PERRLA?
PERRLA is using a light to check if pupils are:
- React to Light
- Accommodate (pupils constrict as objects get closer)
What is the cranial nerves "saying" in order to remember the names of the 12 cranial nerves?
Oh, Oh, Oh! To Touch And Feel A Good Velvet, Such Heaven!
- Spinal Accessory
Draw the cranial nerve face.
This will help you to remember the function and location of the nerves.
What is the function of cranial nerve I?
I. Olfactory: smell
What is the function of cranial nerve II?
II. Optic: vision
What is the function of cranial nerve III?
III. Oculomotor: movement of pupils and eyelids
What is the function of cranial nerve IV?
IV. Trochlear: downward and inward movement of the eyes
What is the function of cranial nerve V?
V. Trigeminal: chewing
What is the function of cranial nerve VI?
VI. Abducens: eye movement lateral (side to side)
What is the function of cranial nerve VII?
VII. Facial: movement of all the facial muscles and taste
What is the function of cranial nerve VIII?
VIII. Acoustic/Vestibulocochlear: hearing
What is the function of cranial nerve IX?
IX. Glossopharyngeal: swallowing and taste
What is the function of cranial nerve X?
X. Vagus: swallowing and speaking
What is the function of cranial nerve XI?
XI. Spinal Accessory: shoulder movement
What is the function of cranial nerve XII?
XII. Hypoglossal: tongue strength