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Question

What is the purpose of completing an assessment and what do you expect to learn about a patient's or situation?

Define Clinical database

Define objective and subjective data. Use the following scenario to identify the subjective & objective data.

Scenario: The nurse is working in the ER when Mr. Smith arrives by wheelchair. He tells the nurse he had a minor surgical procedure at the hospital 3 days ago. He reports pain in his left leg and states he has been unable to walk without his leg hurting for the past day. He is accompanied by his wife who reports Mr. Smith has been limping and complaining of pain. The nurse examines his leg and documents that it is red, swollen and hot to the touch.

What is the subjective data?


What is the objective data?


1.   Sources of data:

A.  Primary -

B.  Secondary -

Using the above scenario about Mr. Smith, what is the primary source of data? What is the secondary source? What other ways can the nurse obtain data about Mr. Smith?


Types of data gathered:

         1)

         2)


2.   What is the focus of a nursing assessment?


3.   Types of assessments: Define each term and list 3 potential problems which might prevent you from completing the assessment.

a.    Patient Centered Interview

a.    Define:

b.   Potential problems:

b.   Physical Assessment

a.    Define:

b.   Potential problems:

c.    Emergency Assessment

a.    Define:

b.   Potential problems:

d.   Periodic Assessment

a.    Define:

b.   Potential problems:


4.   Health history is the __________________________.

Using the scenario above, what does the nurse need to know about Mr. Smith's health history in order to take care of him (provide examples)?



5.   Identify 3 ways you can improve the nurse-patient interaction to improve the patient's comfort level.


6.   Scenario: The nurse enters the clinic room to examine Ms. Taylor, a 24-year old female. The nurse observes her frowning and staring at the floor and notices that Ms. Taylor did not look up when the nurse enters the room. It is January and 24° and Ms. Taylor is not wearing a coat. The nurse sees Ms. Taylor's shirt has a few holes, she is not wearing socks, one of her shoes is untied, and her hair is in a messy bun. She has a large plastic bag next to her on the floor with various articles of clothing. The nurse observes Ms. Taylor biting her fingers and rocking slowly back and forth. When she speaks, she does so with a soft, hoarse voice.


According to Tanner's model, what does the nurse notice as abnormal/concerning assessment findings? What does the nurse anticipate will be the next steps in caring for this patient?

 

 

7.   Assessment Techniques: Define each term and give an example of how you might use this technique to assess a patient. For example, you might use palpation to assess temperature of a patient's skin.

a.    Inspection

b.   Palpation

c.    Percussion

d.   Auscultation

Step-by-step answer

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