NURS 247 Final Exam Questions and Complete Solutions
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Course
NUR 247
Institution
NUR 247
Types of head to toe assessments Basic- min for every pt no matter the population; doesn't matter if on cardio or neuro floor...same on each unit (you add components to it based on the population or units that you're on to make it a focused assessment of that population)
Comprehensive- start at to...
NURS 247 Final Exam Questions and Complete Solutions Types of head to toe assessments ✅Basic - min for every pt no matter the population; doesn't matter if on cardio or neuro floor...same on each unit (you add components to it based on the population or units that you're on to make it a focused assessment of that population) Comprehensive - start at top of head and do every assessment that you know from head to toe (also will hear integrated...anywhere you are on the body you are going to assess everything on that body part instead of doing it by body system Focused - basic + added components specific to the population/unit; would include a problem not just pop/unit 1. BEGIN SHIFT WITH ASSESSMENT OF EHR DATA ✅Prior to entering a patient's room review EHR for: -admitting diagnosis -past medical history -allergies -Medication administration record (list of meds for the day) -abnormal and pertinent normal labs -Baseline vital signs 2. RECEIVE REPORT FROM PREVIOUS SHIFT ✅Take report. Write down: -Admitting diagnosis -Significant past medical history and comorbidities -Allergies and reaction -Significant physical assessment abnormalities -Significant abnormal lab values -Last Vital signs, UO, I/O (input and output) -Last pain med and when next dose due -ivs, drains, machines -Interventions -remaining and ongoing -Ask Questions 3. DETERMINE WHO TO SEE FIRST ✅first level priority -emergent, life threatening, and immediate -ex: ABC + V problems Second level priority -next in urgency, requiring attention so as to avoid further deterioration -ex: dressing change, administering meds Third level priority -important to patients health but can be addressed after more urgent problems are addressed -ex: teaching/coping Collaborative problems -approach to treatment I solves multiple disciplines 4. GO INTO PATIENT ROOM ✅-Gather needed equipment: thermometer, pulse ox, stethoscope -Introduce self as student nurse -Add name to white board -Begin general survey -Instruct patient that you will need to get a morning assessment and get VS Start w basic head to toe then add in elements that create a focused assessment 5. BEGIN ASSESSMENT ✅-Start with VS -Conduct a Focused Assessment - determined by hospital policy's minimum charting fields, unit policy, and patient condition. -Conduct more in depth assessment as determined by Dx and discovered abnormals. BASIC HEAD TO TOE ASSESSMENT ✅-A & O/ Discomfort? -VS (both radial pulses) -Oral assessment -Lung sounds - 4 ant/ 6 post -Heart sounds - all 4 valve areas, S1 S2 -Abdomen sounds -Palpate Abd (LBM/ tenderness/ difficulty urinating?) -Pedal Pulses/ Edema -Posterior skin -I & O FOCUSED ASSESSMENT ✅Add in assessments that are relevant to population or patient problem -Cardiac - EKG, cardiac specific labs -Renal - Dialysis access, renal specific labs -Ortho - ROM, ambulation goals, assistive devices -Oncology - PPE required, oncology specific labs -ICU and Step down - PERRLA, airway, -Surgical - wounds, incisions, drainage GATHER SUBJECTIVE DATA DURING PHYSICAL EXAM ✅Pain Discomfort SOB
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