*NURSING > STUDY GUIDE > NR 302 Exam 1 CASE SESSION with Diane,Chamberlain College of Nursing (All)
NR 302 Exam 1 CASE SESSION with Diane,Chamberlain College of Nursing HIPAA: When could the information about the patient be given out? Patient consent Health care proxy – if it is docume... nted If a patient says they want to kill another patient or you or “I want to kill nurse Devin” Can you relay that information? YES YOU DO! SUBJECTIVE DATA– what the patient tells you OBJECTIVE DATA – what you observe or lab results NURSING PROCESS: ASSESSMENT Collect data General assessment/exam Physical exam Neurological Exam Musculoskeletal Exam Very important to document what on this FIRST ASSESSMENT? 1. Allergies Most important; can be life or death 2. Medications 3. History of diseases ** REMEMBER You’re doing the nursing care plan on what they are admitted for – not what they had in the past unless it correlates Patient comes in and you’re doing an assessment patient says to you: Patient: “I can’t remember at times where I put my keys, wallet, or can’t remember how to get home sometimes” Nurse: “Did you have any recent injuries? Did you fall or hit your head?” Patient: “No it just came on. It’s gradually getting worse” WHAT KIND OF ASSESSMENT WOULD YOU DO OR TESTING? o MENTAL STATUS EXAM BECAUSE HIS FORGETFULLNESS AND MEMORY IS NOT DUE TO AN INJURY – ITS DUE TO A GRADUAL DETERORIATION o This focuses on cognitive disorders Patient States “Oh you know what, 2 days ago I fell off a ladder and got a headache, now I can’t remember where I put my things” WHAT KIND OF ASSESSMENT WOULD YOU DO? [Show More]
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