NSG 2317 Lecture Notes - Lecture 1: Mental Status Examination, Auscultation, Palpation
22 Sep 2016
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The patient trajectory: health issue manifestation, data collection, history, examination c. Nursing process: perform an organized health assessment, validate the data, distinguish normal from abnormal, make inferences/hypothesis, cluster related cues, discern relevant from irrelevant, recognize inconsistencies. Identify missing info: name actual and or potential problems (nursing diag, set priorities! Abc and v: needs ppromt intervention to prevent deterioration, mental status change, acute pain, urinary elimination problems. Important but no threat of imminent or short term harm. Biographical data (bio: name, age and birthday, sex, birthplace, address and phone number. Reason for care provision (cc +hpi: screening vs testing, signs vs symptoms, hpi (history of presenting illness) Understand: patient"s perception of the problem, what do you think it means. Past medical history (pmhx: allergies, medication use, previous/ongoing. Family history (famhx: age and health or cause of death of immediate blood relatives, family tree. Review of systems (ros: general, derm, heent- head, eyes, ears, nose, throat, resp, cardiac, gi, gu, msk, neuro.
