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68C Ph.2 T.1
Assessing Health Status
| Question | Answer |
|---|---|
| ELO> Discuss the differences in responsibilities of the RN and LVN/LPN related to performing a nursing assessment | The RN is responsible for completing the initial assessment as well as documentation. The LPN may provide assistance. |
| ELO> Identify four techniques used to perform a physical assessment | a.Inspection b.percussion c.Palpation d.Auscultation |
| ELO> Explain special consideration taken when performing a nursing physical assessment on an older adult | a.allow adequate time b.monitor for signs of fatigue c.ensure privacy d.toilet accessible e.Explain procedure, avoid medical jargon, speak clearly, objective/subjective data |
| ELO> Identify preventive health care topics to teach to a patient and family while performing an assessment | a.Regular physical exams b.Immunizations c.Periodic diagnostic tests |
| ELO> Differentiate between an admission, a shift-to-shift, and a focused assessment | a.admission- formal head-to-toe b.shift-to-shift beginning of each shift c.focused- when change in condition |
| ELO> Explain how to document | DA 3888 and SF 510 |
| The initial nurse assessment must be performed within the first... | 24 hours |
| Completion and documentation must be done by the | RN |
| Which physical assessment technique is most commonly used? | Inspection |
| When palpation is performed, be sure to list the following characteristics of your findings.. | temperature, texture, vibration, pulsations, masses |
| Which physical assessment is least frequently used? | percussion |
| What are the signs of fatigue? | slumping, sighing, irritability |
| What are some of the physiological considerations of the older adult? | memory difficulty, skin is less elastic/drier, skin turgor-NOT accurate measure of hydration, CHECK MUCOUS MEMBRANES |
| Lentigines | brown spots or liver spots |
| Actinic keratoses (moles) | reddened flaky, precancerous areas |
| Periodic diagnostic tests | blood pressure, cholesterol, blood glucose, breast exam, colon-rectum, cervix, testicle |
| Cancer warning signs | change in bowel/bladder habits, sore that does not heal, unusual bleeding or discharge, thickening or lump in breast, indigestion, change in wart |
| DA Form 3888 | provides nursing hx and assessment. Contains written communication, permanent record for accountability, legal record of care, teaching |
| What is located on the front of the DA 3888 | a.Date b.Time of admission c.Respone to questions d.Name,rank/title of PERSON COLLECTING DATA, name of informant and relationship e.Disposition of articles |
| What is located on the back of the DA 3888 | a.Categories of assessment b.Vital signs c.Signature required d.Assessments reviewed and revised |
| SF 510 | provides chronological record of nursing care, patient status, response to nursing interventions |
| Which form reflects change in condition and results of treatment? | SF 510 |
| When prepping the SF 510, what information is entered? | a.Patient data b.Date and time each entry c.Signature, rank/title of person making entry |
| If DA form 3888 is completed.. | admission note does not need completed on SF 510 |
| If DA form 3888 was NOT completed.. | Admission note must be recorded |
| When documenting Incident reports.. | give observed information, list date/time/care given, include the physician notified REPORT IS NOT included in nurses notes |
| DA form 3888-3 | discharge note, begins at time of admission |
| STAT orders must be documented on the | SF 510 |
Created by:
ajwildasin30
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