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68C Ph.2 T.1

Assessing Health Status

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