SOAP
Subjective
Objective
Assessment
Plan
4 aims of nursing
Promote health by educating and caring
Prevent illness
Treat human response to health or illness (example, administer medications ordered)
Advocate for the individual or family
The nursing process
Assessment - analysis - planning - implementation - evaluation
Types of assessment data
Subjective - statements from the patient or inferences
Objective - measurable, reproducible, and/or observed from the senses
Types of assessments
Comprehensive - head to toe, all bodily systems. Done at beginning of shift and when necessary
Emergency - life threatening
Focused - problem focused, symptom specific
Health history - Done at admission, or if additional information is needed
Assessment techniques
Inspection
Ausculation
Percussion
Palpation
Maslow's hierarchy
Physiological
Safety
Love and belonging
Esteem
Self actualization
ABCCS
Airway
Breathing
Circulation
Consciousness
Safety
Therapeutic communication vs not
Clarifying, exploring, general leading, silence, open ended
False reassurances, giving advice, passing judgement, medical terms, defensiveness
OLDCARTS
Onset duration location character aggravating factors Relieving factors Treatment Scale (pain)
SBAR
Considered best practice
Situation
Background
Assessment
Reccomendation
FACT
Factual
Accurate
Complete
Timing
HIPPA
Health insurance portability and accountability act
Expected heart findings
Pulse 60-100
S1 and s2 sounds (tricuspid and mitral, pulmonary and aortic)
Unexpected heart findings
Arrhythmia/dysrhythmia, murmurs, tachy or brady
Handoff report information
Name age code status diagnosis isolation abnormal assessment findings IVs