Exam (elaborations)
NU 220 HEALTH ASSESSMENT FOR NURSING PRACTICE EXAM 2024/2025 (UAB)
- Course
- NU 220
- Institution
- University Of Alabama - Birmingham
NU 220 HEALTH ASSESSMENT FOR NURSING PRACTICE EXAM 2024/2025 (UAB)
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NU 220 UNIVERSITY OF ALABAMA AT BIRMINGHAMNU 220 HEALTH ASSESSMENT FOR NURSING
PRACTICE EXAM 2024/2025 (UAB)
What is health assessment?
A point of entry, collection of data to formulate a database from which to:
-form diagnoses
-plan interventions
-measure evaluations
What is the nursing process?
Assessment
Diagnosis
Planning
Implementation
Evaluation
start collecting data
make decisions based on assessment
>what we are gonna do to help the patient
plan and implement
,NU 220 UNIVERSITY OF ALABAMA AT BIRMINGHAM
check if they are working by evaluation
Forms of Documentation
Narrative format - information provided in sentences, usually time sequenced
SOAP
PIE
FOCUS
Charting by Exception
Clinical Pathways
SOAP
subjective - everything the patient says
objective - everything the nurse observes
assessment - evaluation (nursing diagnosis/judgement)
plan - what you're going to do
Subjective info to be collected
-HPI [history of present illness]
-ROS [review of systems]
,NU 220 UNIVERSITY OF ALABAMA AT BIRMINGHAM
Signs and symptoms
Symptom - patient experience/what a patient is feeling
>abbreviated as Sx [Sx bar] [w + bar over x] or S/Sx
Sign - what is found/the nursing diagnosis
Organization of note
-general to specific
-highlight remarkable findings
>remarkable means "of note"
>remarkable to unremarkable
4 components of exam
Inspection - what you see
Palpation - what you feel thru touch
Percussion - what you feel/hear thru vibration
Auscultate - what you hear
Inspection
, NU 220 UNIVERSITY OF ALABAMA AT BIRMINGHAM
-general
-detailed
-requires good lighting
-other tools
>penlight
>magnifying glass
>measuring tape/ruler
-ophthalmoscope, otoscope
-specula
Palpation
-temperature
-tenderness
-texture
-moisture
-rigidity/flaccidity
-strength
-masses
-crepitation: creaky-ness
percussion
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