Health Assess Ch. 04: Nursing Data Collection, Documentation & Analysis – Flashcards
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verifies assessment data that you have gathered from the client. 1. determine which data require validation 2. implement techniques to validate 3. identify areas that require further assessment data
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validation; definition & 3 steps
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the act of recording the client assessment findings 1. understand purpose of documentation 2. learn which information to document 3. follow documentation guidelines for the given health care facility
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documentation
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when coming in contact w/ body fluids
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when should you wear gloves when doing a physical assessment?
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2.5-5 cm
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how many cm is 'deep' palpation?
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(phys assess doesn't match what patient told you re-ask questions, clarify re-test check previous health records) 1. repeat assessment 2. clarify data w/ client 3. verify w/ another health care professional 4. compare findings
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HOW do you validate your data?
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(make sure plan of care is appropriate communicate to others) 1. chronolog source of data 2. prevents fragmentation/repetition 3. basis for screening 4. diagnose new problems 5. determine educational needs 6. eligibility for reimbursement 7. legal record of care
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purposes of documentation
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1. subj/biographic data 2. coldspa...
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what do you document?
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1. don't use 'normal'... it's meaningless. be objective 2. use phrases instead of sentences (not "upon palpation, blah blah blah" just write what you're doing) 3. include client's understanding (describe this by documenting their verbal responses to your teaching...) 4. record data findings, not how they were obtained 5. record what you see, NOT the medical diagnosis (two pts could both have bronchitis w/ very diff symptoms)
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guidelines for documentation
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provides for narrative description
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what is a feature of an open-ended document form?
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standards of care, scope of duty
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Nurse Practice Act
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* based on diagnosis or condition * lifestyle risk factors (smoking & drinking)
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how do you cluster all the data?
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info derived from research; make an educated decision based on that. don't just do something because that's the way it's always been done.
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what is evidence-based knowledge
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don't want to use any practices that have been proven to not work!
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what is evidence-based knowledge needed for nursing?
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is problem solving; much like the nursing process!
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critical thinking
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pt considers self to be well/healthy; they're just seeking education
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wellness diagnosis
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nursing diagnoses define the symptoms as opposed to just labeling
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how is nursing diagnosis different from medical diagnosis?
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1. don't jump to conclusions 2. practice! get the skill down, do it in the right order
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how do you avoid mistakes?
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time person place
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what should a 'with-it' person be oriented to?
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they response appropriately; don't laugh if tell them they have cancer
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how do you assess mood/affect?
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appropriate wording? can they articulate? speech slurred?
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assessing speech
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yes
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does drawing a clock require higher cognitive function?
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early teens
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when do you develop the ability to abstract?
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a pt who awakes to vigorous shake or painful stimulus but returns to unresponsive sleep
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stuporous
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open eyes, answer quesitons correctly, then fall back asleep
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lethargic
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opens eyes to loud voice, response slowly w/ confusion, seems unaware of envi
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obtunded
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unresponsive to all stimuli; eyes stay closed
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com
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do they open their eyes spontaneously?
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what does Glasgow coma scale assess?
