PRIORITY SETTING:
FIRST ADDRESS ANY LIFE-THREATENING SITUATIONS
o And then other issues that need immediate attention
INVOLVES USING
o Knowledge
o Cli
... [Show More] nical experience
o Expertise
o Judgement
Life threatening issues
o Circulation
o Airway
o Breathing over elevated temperature
o Human violence
o Suicide
Priority Levels
o First Level: Life threatening (ABCs + V)
o Second level: Urgently require treatment to prevent deterioration
o Third Level: Important, but can wait for stabilization of first and second levels
o Collaborative: Approach requires multiple disciplines of caregivers
THREE TYPES OF NURSING ASSESMENTS:
1) Emergency and Urgent Assessment
o Center on immediate & highest priority problem
o Life threatening or unstable situation
o Nurses obtain details until patient is stable
o Most common
Chest pain **TREATED IMMEDIATELY MYOCARDIAL INFARCTION
Back pain
Headache **TREATED IMMEDIAETLY – CEREBEAL HEMORRHAGE
o Includes
Medication
Allergies
Current health problems
Reason for seeking care
Extreme anxiety
Acute distress
Pallor
Cyanosis
Change in mental status
o ABCDE
A: Airway (cervical spine protection if an injury is suspected)
B: Breathing (rate and depth, use of accessory muscles)
C: Circulation (pulse rate and rhythm, skin color )
D: Disability (level of consciousness, pupils, movement )
E: Exposure
o Critical Interventions:
Provide assistance with circulation
Open patient’s airway
Assist the patients breathing
Protect the cervical spine if the patient is injured
Ensure that the disoriented or suicidal patient is safe
Provide pain management and sedation
2) Comprehensive Assessment (???each unit )))
o Complete health history and Physical Assessment
o Includes all body systems and areas
o Includes
Demographics
Family history
Individual health history
Psychosocial areas
o Reason of seeking care
o Head to toe format
Assessment of skin
Head, neck, eyes, ears, nose, mouth, throat, thorax and lungs, neurologic
systems
o Ex) physical required by school, annual PE, hospital admission, Sports Part. Screening
o History might be obtained by patient filling out with family history of illness, personal
illness, and medical treatment or surgeries
o Can obtained secondary information from family members
o Includes patient perception of health,
strengths to build on
risk factors for illness
functional abilities
methods of coping
support systems
o Note
dates of diagnoses
treatments
reason for medication
important to reconcile the medication list
3) Focused Assessment
o Involves questions that relate to the current situation
o Based on patient’s health issues
o Involves one or 2 body systems
o Smaller in scope than the comprehensive assessment BUT more in depth on the specific
issues or issues
o Ex) patient with a cough
Focuses on duration of the cough
Associated symptoms such as wheezing or shortness of breath
Factors that relieve or worsen the cough
PA: evaluation of the nose and throat, auscultation of the lungs, inspection of
septum
4) Follow Up Assessment:
o Performed 30 to 60 days later
o Determines whether patient’s medication is working
o Determines if patient needs further teaching or different treatments
o Ex) Diabetes ( follow up on HBP)
EVIDENCE BASED PRACTICE
Approach to patient care that minimizes intuition and personal experience and instead
relies on research findings and high- grade scientific support
Three aspects
o Best evidence according to research
o Best evidence according to Nurses expertise
o Patient Preference
Helps solve common problems through four steps
o Clearly Identify the issue or difficulties based on accurate analysis of current
nursing knowledge and practice
o Search the literature for relevant research
o Evaluate the research evidence using established criteria governing scientific
merit
o Choose interventions and justify the selection with the most valid evidence
Some evidence is evaluated in
COMMUNICATION:
PATIENTS WITH LIMITED ENGLISH SKILLS:
Obtain an interpreter if patient uses another primary language
o Keep in mind translators are costly
- Cover one concept at a time
- Use simple words or phrases
- Pantomime questions: such as pretending to be in pain
- Resources with pictures are helpful
- Principles
o Limitations in language are NOT a reflection of intellectual functioning
o Patients tend to think in their native language and translate= delayed response
o Patients interpret the message that reflects their cultural beliefs, often changing
the speaker’s intent
o Written information in the native language supports verbal communication
WORKING WITH AN INTERPRETER
- Establish need during patients first contact
- When is a trained medical interpreter needed?
o Sensitive topics such as end of life care
o Permission for consent to treat
o Admission assessment
o Complex treatments
Performing clinical trails
The Cochrane Database
MEDLINE
Relies on research finding and high grade scientific support
IMPORTANT TO NOT BASE YOUR PLAN OF CARE BASED ON YOUR PERSONAL
EXPERIENCE BUT INSTEAD ON MEDICAL UP TO DATE DECISIONS.
o Patient education
o Informed consent
o Discharge planning
- Interpreter may check in with patients daily
o Have list of questions and areas for patient teaching [Show Less]