NR 302: Health Assessment Exam 1
CAS SESSION
HIPAA: When could the information about the patient be given out?
• Patient consent • Health care proxy – if it is documented If a patient says they want to kill another patient or you or “I want to kill nurse Devin”
SUBJECTIVE DATA– what the patient tells you OBJECTIVE DATA – what you observe or lab results
NURSING PROCESS:
ASSESSMENT
• Collect data • General assessment/exam • Physical exam • Neurological Exam • Musculoskeletal Exam • Very important to document what on this FIRST ASSESSMENT? 1 / 2
1.
- Medications
- History of diseases
You’re doing the nursing care plan on what they are admitted for – not what they had in the past unless it correlates
Patient comes in and you’re doing an assessment patient says to you:
• Patient: “I can’t remember at times where I put my keys, wallet, or can’t remember how to get home sometimes” • it just came on. It’s gradually getting worse”
• WHAT KIND OF ASSESSMENT WOULD YOU DO OR TESTING?
- MENTAL STATUS EXAM BECAUSE HIS FORGETFULLNESS AND MEMORY IS NOT
DUE TO AN INJURY – ITS DUE TO A GRADUAL DETERORIATION
- This focuses on cognitive disorders
Patient States “Oh you know what, 2 days ago I fell off a ladder and got a headache, now I can’t remember where I put my things”
• WHAT KIND OF ASSESSMENT WOULD YOU DO?
• BECAUSE NOW THERE IS INJURY TO THE BRAIN
- Brain probably rattled
- You have edema
- You have intercranial pressure
- / 2
Sociocultural Background Influences non-verbal behavior