NURS253 Lecture Notes - Lecture 1: Nursing Diagnosis, Nursing Process, Problem Solving
20 Feb 2019
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Following up the comprehensive assessment labs, edema, i&o. Subjective - past heath history, family history, lifestyle and health practices. Initial assessment is when they first come into the healthcare system. How do you feel about having to seek health care: reason for seeking care, what is your major health problem or concern at this time, history of present health concern. Have them explain in detail - onset, progression, duration, what makes it worse and better, any treatments they"ve tried, affect on adls. Childhood illnesses, immunizations, adult illnesses, surgeries, allergies (drugs, food, latex, pollen), medication use (otc"s, herbals), pregnancies: family health history. Document descriptions and any denials activity level, sleep, substance use (nicotine, alcohol, etc. Complete least invasive first while infant is quiet: special populations, newborn, make sure infant is undressed, make sure caregiver understands what will happen, children and adolescents. Allow them to play with the equipment first.
