作者：Renee Bollenbach 4 年以前
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These are assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective
Mood and Affect can have a profound affect on Mental Health to document assessments nurses have to use evidenced based tools to document changes. What EBT Are listed in Mood and Affect that will assist in identifying normal from abnormal?
health assessment includes bringing the concepts together. Can you define the mendelian characteristics? What is a Phenotype? The introduction of genetics lends itself to the family health assessment.
Interoperability, EMR, EHR, CPOE; what are they or rather can you recite what the term(s) mean which includes definitions.
When thinking about technology we have to think about safety; think legal consequences; think requirements to confidentially and confidence in your documentation.
HIPAA. What actions can the implement when using healthcare technology to protect your documentation and wrongful documentation by a colleague? Keep it simple log off your computer before you consider moving away from the computer, keep conversations on the hospital cell phone to inside the nursing station.
Safety in healthcare EHR technology has benefited many patients with CPOE. Computer physician order entry is a part of QSEN. https://qsen.org/quality-and-safety/
Please read the hyperlink
Know how to use the technology, become competent in use and operation of the device, what physiologic symptom(s) can impair a normal reading and what will you do to obtain a reading that is true reflection of the patients hemodynamic state.
Thinking about the bladder scanner; Cn you identify when you would use one and why it would be used? Think about your patients; when you remove a foley what are your nursing considerations? When would a bladder scan be used after a foley is removed?
Telehealth
Telehealth what are benefits of the health care technology? Virtual visits reduce person / person contact - reducing spread of infections; provides less of a carbon foot print for traveling back and forth too the health care providers location; is secure
It does not have time constraints or easy to use for everyone nor does everyone have internet access.
Mobile appa
Can help society members remember to take their medication, communicate with the provider by connecting over internet, can forward information like glucose readings, blood pressures, etc....
Asking questions in a health history is integral to any complete assessment. Reproductive questions can cause awkwardness and unease for some nurses, some patients and at times both nurses and patients. Remember to ask open ended questions and wait for a reply.
Male Assessment- would you be able to identify from the answer choices: correct documentation between abnormal and normal health assessment findings; can you identify correct documentation of the assessment, how often they should be performed,
Put your critical thinking hat on to determine why a patient is having hesitancy on the attempt to urinate. Ask the patient questions recent regarding history, how often the hesitancy occurs, is it painful, hx of Prostrate enlargement in the family.
Breast Assessment - Abnormal / normal; if abnormal the nurse should verify if this is a new finding; proper positing to exam is sitting (for this exam); proper assessment for palpating is use of flat pad on three fingers
When you begin your health assessment you will inspect each breast and comparing them to each other for: color, size, shape, wounds, nodules, scaring, drainage and dimpling. Palpate each breast using the pads of your fingers, noting differences and similarities. You will ask questions for Pain, discomfort,drainage ( know for the future expression of breast milk is a common finding in woman starting depression medications), or changes the patient has noticed that are (is) new,
When you are documenting know in many EHR’s the definition of normally are listed in the health assessment column. For example Normal: breasts are equal in size, patient denies pain, skin is in tack and no new changes. Whereas Abnormal you would chart - any finding that contradicts Normal and then some, R breast > in size from L breast, patient reports this is new or not new.
Violence Assessment - If given an event that requires the nurse to identify between answer choices, “leads you to suspect IPV”: Partner does not let patient speak, repeated injuries and emergency room visits, patient or partner stating the patient is clumsy / accident prone......
How would you reply to someone who Reports?
Nursing consideration: Support and build trust, avoid advice and suggestions, do not promise anything to the reportee
Signs of Abuse * frequent visits to ER
