In the beginning… Chapters 1, 2, 3, 4 and ATI Nurse Functions To aid individuals sick or well, in performing activities contributing to health or recovery. How? P____________ P____________ P____________ of I____________ O____________ of H___________ T_____________ of D____________ A___________ of I_____________, F___________, C____________, P___________ Copyright © 2020 by Elsevier, Inc. All rights reserved. 2 How does a Nurse Help P___________________ PSY________________ S___________________ SP__________________ EN_________________ H___________________ Copyright © 2020 by Elsevier, Inc. All rights reserved. 3 Nursing Process A__________________ D__________________ P__________________ I___________________ E___________________ Copyright © 2020 by Elsevier, Inc. All rights reserved. 4 Nursing Priority Problems vs. Medical Diagnosis Nursing Priority Problem Holistic focus Medical Diagnosis Disease focus Collaborative Care SBAR S___________ B____________ A_____________ R________________ Copyright © 2020 by Elsevier, Inc. All rights reserved. 6 SBAR Delegation UAP…Unlicensed Assistant Personnel (CNA. Med Tech) Licensed Practical Nurse (LPN) Only RN Copyright © 2020 by Elsevier, Inc. All rights reserved. 8 Electronic Health Record (EHR)…Where does the information go? Copyright © 2020 by Elsevier, Inc. All rights reserved. 9 Evidence Based Practice (EBP) Uses the best available evidence (research, quality improvement data, etc.) combined with the nurse’s expertise to make the best decisions for the patient. Where do we find this information? Copyright © 2020 by Elsevier, Inc. All rights reserved. 10 Health Disparities What is Health Disparities? What kind of factors contribute to health disparities? How do we fix health disparities? Copyright © 2020 by Elsevier, Inc. All rights reserved. 11 Culture What is culture? How does culture affect healthcare? Does religion have anything to do with culture? Does religion have anything to do with healthcare? How do you know if a patient belongs to a certain culture/religion? What is cultural competence? Does it only apply to patients? Copyright © 2020 by Elsevier, Inc. All rights reserved. 12 Culturally Competent Care Assessment Know cultural norms Ask about cultural values Same gender preference Copyright © 2020 by Elsevier, Inc. All rights reserved. 13 Patient is not English speaking What does a nurse do? Copyright © 2020 by Elsevier, Inc. All rights reserved. 14 National Patient Safety Goals Joint Commission Identify patients correctly Get important test results to the right staff person on time Use medicines safely Prevent infection with hand washing Prevent mistakes in surgery Copyright © 2020 by Elsevier, Inc. All rights reserved. 15 Assessment Patient’s health history Physical examination Identify patient’s current and past health status Provide baseline for further evaluation Formulate nursing priority problem Copyright © 2020 by Elsevier, Inc. All rights reserved. 16 Data Collection Nursing focus…support priority problems Types of data Subjective Objective Interview considerations Symptom investigation Data organization…Follow same sequence all the time Patient comfort, safety, and privacy Record Copyright © 2020 by Elsevier, Inc. All rights reserved. 17 Data Collection Copyright © 2020 by Elsevier, Inc. All rights reserved. 18 Subjective Data Important health information What the patient/family tells the nurse Health history (including recent illness, major childhood and adult illnesses, injuries, hospitalizations) Medications (all, including OTC, herbals, vitamins, illegal) Allergies Surgery or other treatments Functional health patterns Copyright © 2020 by Elsevier, Inc. All rights reserved. 19 Data Collection…Functional Health Pattern Subjective Data…Functional Health Patterns 1 Health perception–health management pattern • Perceived level of well-being. Personal practices for maintaining health Nutritional–metabolic pattern • Ingestion, digestion, absorption, and metabolism are assessed from a 24-hour diet recall to evaluate the quantity and quality of foods and fluids consumed. Assess the impact of psychologic factors and socioeconomic and cultural factors, the patient’s present condition, food allergies, and food intolerances on diet and nutrition Elimination pattern • Bowel, bladder, and skin function Activity–exercise pattern • Pattern of exercise, work activity, leisure, and recreation. Ability to perform activities of daily living Copyright © 2020 by Elsevier, Inc. All rights reserved. 21 Subjective Data…Functional Health Patterns 2 Sleep–rest pattern • Pattern of sleep, rest, and relaxation in a 24-hour period. Cognitive–perceptual pattern • Description of all of the senses and cognitive functions. In addition, pain is assessed as a sensory perception Self-perception–self-concept pattern • Patient’s self-concept, including attitudes about self, perception of personal abilities, body image, and general sense of worth Role–relationship pattern • Roles and relationships of the patient, including major responsibilities Copyright © 2020 by Elsevier, Inc. All rights reserved. 22 Subjective Data…Functional Health Patterns 3 Sexuality–reproductive pattern • Satisfaction or dissatisfaction with personal sexuality and describes reproductive issues Coping–stress tolerance pattern • Specific stressors or problems that confront the patient, the patient’s perception of the stressor, and the patient’s response to the stressor Value–belief pattern • Values, goals, and beliefs (including spiritual) that guide health-related choices Copyright © 2020 by Elsevier, Inc. All rights reserved. 23 Subjective Data… Investigation of Patient Reported Symptoms P_____________ Q_____________ R_____________ S_____________ T_____________ Copyright © 2020 by Elsevier, Inc. All rights reserved. 24 Pain Scales FLACC Physical Examination:Objective Data General survey Physical examination Techniques (in this order) • • • • Inspection Palpation Percussion Auscultation Abdomen • • • • (exception) Inspection Auscultation Percussion Palpation Copyright © 2020 by Elsevier, Inc. All rights reserved. 26 Physical Examination: Objective Data Copyright © 2020 by Elsevier, Inc. All rights reserved. 27 Physical Examination: Objective Data Palpation Light, Deep What is this used for? Percussion Tapping on a finger What sounds may you hear? Auscultation Bell, Diaphragm What sounds may you hear? Copyright © 2020 by Elsevier, Inc. All rights reserved. 28 Types of Assessment Emergency assessment Comprehensive assessment Focused assessment Copyright © 2020 by Elsevier, Inc. All rights reserved. 29 What type of assessment will you do? A patient on your med-surg unit calls you in to tell you she cannot breath. A patient was admitted to your floor at 8am. Her diagnosis is Heart Failure. It is now 12 noon, and the patient reported no changes during the morning. The patient is rushed into the Emergency Department with abdominal pain. A patient is admitted to your med-surg unit after a left leg amputation. Copyright © 2020 by Elsevier, Inc. All rights reserved. 30 Types of Assessment Learning assessment Copyright © 2020 by Elsevier, Inc. All rights reserved. 31 Question When obtaining an initial health history from a patient who immigrated to the United States several years ago, it is most important for the nurse to first: a. ask permission to touch the patient. b. explain to the patient the values and beliefs of his or her own culture. c. determine the extent of the patient’s identification with a cultural group. d. engage the patient in general, nonthreatening conversation when performing auscultation. Copyright © 2020 by Elsevier, Inc. All rights reserved. 32 Question The nurse takes a health history and performs a physical examination on a patient admitted to the hospital. The nurse would be most concerned if what occurs? a. The patient reports intermittent abdominal pain. b. The patient requests the presence of a family member. c. The patient suddenly develops severe shortness of breath. d. The patient is unable to provide a list of current medications. Copyright © 2020 by Elsevier, Inc. All rights reserved. 33 Question Which of the following are subjective data that the nurse collects in the course of an assessment? Select all that apply a.Nausea b.Shortness of breath c.Malaise d.Abdominal pain Copyright © 2020 by Elsevier, Inc. All rights reserved. 34 Question Which of the following requires the nurse to perform an emergency assessment? a. The patient with a respiratory rate of 60, nasal flaring, and supraclavicular retractions. b. The patient's family reports that the patient has not had a bowel movement in 4 days c. The patient with new onset of abdominal pain, rated 5 on 0-10 pain scale. d. The patient with a blood pressure 156/90 Copyright © 2020 by Elsevier, Inc. All rights reserved. 35 Question During the course of a comprehensive assessment completed by the nurse, the patient complains of abdominal pain. What is the nurse's next step? a.Document the findings b.Continue with the next system to be assessed c.Stop the assessment d.Investigate the symptom using PQRST Copyright © 2020 by Elsevier, Inc. All rights reserved. 36
