NURS 3320 /NURS 3320 ASSESSMENT EXAM 2 COMPLETE STUDY GUIDE. A+ RATED.
1. Recognize what types of client statements may need validation.
Discrepancies o... [Show More] r gaps between objective and subjective data. Ex: Pt says he’s happy despite learning that he has terminal cancer
Discrepancies or gaps between what the client says one time vs another time. Ex: patient says they have never had surgery but later states they had their appendix removed
Finding that are highly abnormal with other findings. Ex: Pt has a temp of 104 degrees while resting comfortably and skin is warm to the touch and not flushed.
2. Recognize examples of appropriate and inappropriate documentation.
• Document legibly, use correct spelling and grammar
• Avoid wordiness
• Use phrases
• Record data findings, not how they were obtained
• Do not make judgments
• Record clients’ understandings of problems
• Avoid the word “normal”
3. Identify appropriate methods for validating
Recheck data- by repeating the assessment. For example, take the client’s temperature again with a different thermometer.
Clarify data- by asking the client additional questions. For example, if a client is holding his abdomen the nurse may assume he is having abdominal pain, when actually the client is very upset about his diagnosis and is feeling nauseated.
Verify the data- ask another health care professional. For example, ask a more experienced nurse to listen to the abnormal heart sounds you think you have just heard.
Compare objective and subjective data- to uncover discrepancies between your findings and what the patient says. For example, if the client states that she “never gets any time in the sun,” yet has dark, wrinkled, suntanned skin, you need to validate the client’s perception of never getting any time in the sun by asking exactly how much time is spent working, sitting, or doing other activities outdoors. Also, ask what the client wears when engaging in outdoor activities.
4. Discuss purposes and principles of documentation.
Purpose of documentation
The primary reason for documentation of assessment data is to promote effective communication among multidisciplinary health team members to facilitate safe and efficient client care. It helps to identify health problems, formulate nursing diagnoses, and plan immediate and ongoing interventions. Two key elements need to be included in every documentation: nursing history and physical assessment, also known as subjective and objective data.
Guidelines of documentation
1. Keep confidential all documented information in the client record. Clients must also be educated on their rights in relation to HIPAA.
2. Document legibly or print neatly in nonerasable ink. Errors in documentation are usually corrected by drawing one line through the entry, writing “error,” and initialing the entry. Never obliterate the error with white paint or tape, an eraser, or a marking pen.
3. Use correct grammar and spelling. Use only abbreviations that are acceptable and approved by the institution.
4. Avoid wordiness that creates redundancy.
5. Use phrases instead of sentences to record data.
6. Record data findings, not how they were obtained.
7. Write entries objectively without making premature judgments or diagnoses.
8. Record the client’s understanding and perception of problems.
9. Avoid recording the word “normal” for normal findings.
10. Record complete information and details for all client symptoms or experiences.
11. Include additional assessment content when applicable.
12. Support objective data with specific observations obtained during the physical examination.
5. Describe correct procedure for validating telephone and verbal orders.
Use a standardized method of data communication such as SBAR
Communicate face to face with good eye contact.
Allow time for the receiver to ask questions.
Provide documentation of the data you are sharing.
Validate what the receiver has heard by questioning or asking him or her to summarize your report.
When reporting over a telephone, ask the receiver to read back what he or she heard you report and document the phone call with time, receiver, sender, and information shared.
6. Identify risk factors for skin cancer.
Skin cancer is the most common of cancers. It occurs in three types: melanoma, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC). BCC and SCC are nonmelanomas.
BCC is the most common skin cancer in Caucasians, whereas SCC is the most common in darker skin. Asians are less susceptible to skin cancers. African Americans, Asians, and Hispanics, although less susceptible than Caucasians, are susceptible to melanoma.
Nonmelanocytic skin cancers are the most common worldwide and are also increasing in populations heavily exposed to sunlight, especially in areas of ozone depletion. Malignant melanoma is the most serious skin cancer. It is the most rapidly increasing form of cancer in the United States.
Risk Factors for Skin Cancer:
• Sun exposure, especially intermittent pattern with sunburn; risk increases if excessive sun exposure and sunburns began in childhood.
• Nonsolar sources of UV radiation (tanning booth, sunlamps, high-UV geographical areas). Indoor tanning is listed as one of the most dangerous cancer-causing substances (along with plutonium, cigarettes, and solar radiation).
• Medical therapies such as PUVA and ionizing radiation
• Family or personal history and genetic susceptibility (especially for malignant melanoma)
• Moles, especially atypical lesions
• Pigmentation irregularities (albinism, burn scars)
• Fair skin that burns and freckles easily; light hair; light eyes
• Age; risk increases with increasing age
• Actinic keratoses
• Male gender (for nonmelanoma cancers), especially white men over 50
• Chemical exposure (arsenic, tar, coal, paraffin, some oils for nonmelanoma cancers)
• Human papillomavirus (nonmelanoma cancers) [Show Less]