Patient and Caregiver Teaching
Patient and Caregiver Teaching Role of Patient and Caregiver teaching General goals for patient teaching include Health promotion Disease prevention Illness management Selection and use of appropriate treatment options A teaching plan includes Assessment of the patient’s ability and readiness to learn Identification of teaching needs Development of learning goals with the patient Implementation of […]
Outline for physical examination
Outline for physical examination General survey Observe general state of health Vital signs Record vital signs such as: Blood pressure Pulse rate (apical/radial pulse) Respiration rate Temperature Oxygen saturation Integumentary/skin Inspect and palpate skin and nail Head and neck Inspect and palpate face, sinuses, and central nervous system Extremities Observe size and shape, symmetry and […]
Types of Assessment
Types of Assessment Emergency assessment Limited to assessing life-threatening conditions (e.g., inhalation, injuries, anaphylaxis, myocardial infarction, shock, stroke) This involves a rapid history and examination of a patient while maintaining vital functions. Conducted to ensure survival. Focuses on elements in primary survey (e.g., airway, breathing, circulation, disability) Comprehensive assessment Typically done on admission to the […]
Objective Data Nursing History
Objective Data General Survey Physical Examination Techniques Inspection Visual examination of a part or region of the body to assess normal conditions or deviations and by comparing Palpation Using light and deep palpation can yield information related to masses, pulsations, organ enlargement, tenderness or pain, swelling, muscular spasm or rigidity, elasticity, vibration of voice sounds, […]
Nursing History
Nursing History Subject Data Important Health Information Past health history Major childhood and adult illnesses, injuries, hospitalizations, and surgeries Medications Past and current medications, including prescription and illicit drugs, over-the-counter drugs, vitamins, herbs, and dietary supplements. Question older adult and chronically ill patients about medication routines. Allergies Fully explore the patient’s history of allergies to […]
Role of Nursing Personnel
Role of Nursing Personnel Role of Registered Nurse (RN) On admission, complete a comprehensive assessment. Obtain patient’s health history by interviewing patient and/or caregiver. Perform physical examination using inspection, palpation, percussion, and auscultation as appropriate. Document findings from the health history and physical examination in the patient’s record. Organize patient data into functional health patterns, […]
Investigation of Patient-Reported symptoms
Investigation of Patient-Reported symptoms Factor Questions for Patient and Caregiver Record P Precipitating and Palliative Were there any events that came before the symptoms? What makes it better or worse? What have you done for the symptom and did it help? Influence of physical and emotional activities. Patient’s attempts to alleviate (or treat) the symptom […]
The 12 step program is a set of guidelines designed as a guide towards recovery.
12 Step Program The 12 step program is a set of guidelines designed as a guide towards recovery. They are as follows: We admitted we were powerless over alcohol—that our lives have become unmanageable. The common welfare of the group should come first and that personal recovery depends upon Alcohol anonymous unity. Came to believe […]
Nursing diagnosis : Risk for trauma/falls
Nursing diagnosis Risk for trauma/falls Due to impaired physical mobility, Loss of muscle strength, disorientation, presence of illness, use of medications Hypothermia Age-related changes in thermoregulation and environment exposure Reduction in body temperature below the normal range Shivering Cool skin Pallor Tachycardia Decreased cardiac output Can lead to reduced brain oxygenation, and age-related diminished cardiac […]
Control of the Decision-Making process
Control of the Decision-Making process Patient Self-Determination Act Require that healthcare facilities provide clear, written information to every patient regarding his or her legal rights to make health care decisions, including the right to accept or refuse treatment. It also establishes the right of a person to provide written treatment directions for clinicians in the […]