What is the role of the professional nurse in health assessment?
promote health
prevent illness
treat human responses to health or
... [Show More] illness
advocate
nursing process
traditional critical thinking competency that allows nurses to make clinical judgments and take actions based on reason
assessment, diagnose, outcome identification, planning, implementation, evaluation
health history
subjective data-what patient tells you
symptoms
physical assessment
objective data-signs, direct observation
What is the importance of documentation?
legal document of patient's health status
baseline for evaluation
HIPAA
no bias
SOAP(IE) note
subjective
objective
assessment
plan
intervention
evaluation
PIE note
Plan
Intervention
Evaluation
DAR
Data
Action
Response
CBE
charting by exception
uses pre-determined standards to record relevant info
SBAR
verbal note!
Situation
Background
Assessment
Recommendations/Read back
health
a state of complete physical, mental, and social well-being and not merely the absence of disease
specific to each individual and based on experience, upbringing, race/ethnicity, sexual identity, culture, values
biomedical health
absence of disease
doctor's view
holistic health
the view that the mind, body, and spirit are interdependent and function as a whole within the environment
nursing view
health promotion
wellness
a dynamic process and view of health
a move toward optimal functioning
positive state of health
levels to prioritize problems
first level-life threatening
second level-mental status change, labs
third level-important healthcare issues that can be addressed after urgent issues
how to set priorities with issues
airway
breathing
cardiac/circulation
vital sign concerns
critical thinking
active, organized, cognitive process used to carefully examine one's thinking and the thinking of others
purposeful, based on nursing process and scientific method
continuously re-evaluate
basic critical thinking
concrete and based on a set of rules
early step in developing reasoning
not enough experience to individualize
complex critical thinking
analyze and examine choices independently
look beyond expert opinion
thinkers separate self from experts
each solution has risks and benefit
data analysis
interpretation and clinical judgment
identify abnormal findings-interpret and select plan of care
diagnostic reasoning
PES statement-problem, etiology, symptom
actual diagnosis
describes human response to health conditions/life processes that exist in an individual, family, or community
related to....as evidenced by [Show Less]