NUR1 239 Lecture Notes - Lecture 1: Cardiac Output, Aorta, Hypotension
10 May 2016
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I : indentify (yourself and the person(pt, physician, family, etc) Why you are calling, at the begening of conversation* B : backgroundstory, relevant info only, less is often more, exam, investigation and management. State your thinking, your interpretation, stating the obvious, degree of certainty. State what you want from them, come over to ass, ask question on rx, tx) Decrease assumptions, call obvious at the outset. What the person says about himself of herself, during history. Palpation, with fingertips (light or deep) (texture, temp (back of fingers), moisture, organ location, swelling, vibration (base of fingers), rigidity, crepitation, lumps, masses, terderness or pain) Percussion (direct or indirect) (resonant, hyperresonant, tympany, dull, flat + amplitude, pitch, quality, duration) Clinical judgment about actual or potential health state and identification of their health concerns, risks, and goals in response to the nurse""s analysis. To eveluate the response of whole person to actual or potential health problems.
