Study Guide Exam 1 - Core Study Guide Exam 1 Module 1...

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Core Study Guide Exam 1 Module 1 Professionalism and ANA Code of Ethics: Ethics and Professionalism (2) o Knowledge of Ethics (1) o Student nurse role & responsibility (1) o Principle of Caring (1) o Assessment Concept: 1A ATI p.223 Assessment (5) A.) Complete Assessment: Thorough physical assessment, more systemic assessment than normal. Head-to-Toe. Including listening to heart and lungs, abdomen, etc. B.) Focus Assessment: More in depth assessment, focusing on specific area of concern. Ex. Abdomen, neuro, cardio, respiratory, cranial, musculoskeletal C.) Brief Assessment: 10 minute head-to-toe, bedside assessment (what we are being tested on) Data Collection (5) A.) Methods: Observing Interviewing : asking open-ended question. Provide appropriate setting, comfort and privacy. Active listening, show undivided attention. AIDET (intro) Documenting (body) Closing (thank you, I’ll be back do you need anything else) Examining : ensure privacy, comfort, protect HIPAA. Avoid dominance, sit at same level of patient, etc. Remove all distractions. o Inspect/look o Palpate/feel o Auscultate o Percussion * Exception: abdomen is look listen feel* Health History p.224 General Survey p.230 B.) Sources: Primary – patient Secondary – family, translator, interpreter, anything that is not the patient
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C.) Types : Subjective – symptoms, pain, anything patient feels and you cannot visually observe Objective – anything that you can directly observe or measure. Ex. Skin discoloration, vitals, lab levels, LOC, orientation, nutrition, etc. D.) Organization: SBAR forms, charting Data Validation and Documentation (2) A.) Validate – refer to patient history if available, ask patient what are they feeling/what is their ‘norm’. B.) Reassess after intervening C.) Consider – do the lab values match how they look and feel D.) Interpret – take all data and form a professional opinion; investigate.
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