observing our patients during first encounter

This week, we will dig a little bit deeper into the assessment process and discuss all of the information that can be acquired simply by observing our patients during that first encounter with them through the completion of the general survey. This brief simple observation provides you with not only the information that is needed to quickly alert you to signs of distress or decline, it can also provide valuable insight into the status of the individual’s integumentary and nutritional statuses as well as those are often the first areas noticed upon entry.

This week, we will complete the following.

  • Describe the process of conducting a general survey. (CO 5)
  • Differentiate normal from abnormal findings in the assessment of the integumentary system. (CO 1)
  • Identify anatomical, developmental, psychosocial, and cultural variations that guide assessment of the integumentary system. (CO 2)
  • Describe the skills and techniques required to assess the integumentary system and document findings. (CO 2)
  • Develop questions to be used when completing a focused interview for the integumentary system. (CO 3)
  • Discuss the focus areas related to overall health of the integumentary system in Healthy People 2020 (2014) initiatives. (CO 4)
  • Develop questions to be used when completing a focused interview related to nutritional status. (CO 3)
  • Differentiate between normal and abnormal findings in a nutritional assessment. (CO 1)

Outcomes

1

Utilize prior knowledge of theories and principles of nursing and related disciplines to explain expected client behaviors, while differentiating between normal findings, variations, and abnormalities. (PO #1)

Weekly Objectives

  • Discuss the phases and components of the general survey.
  • Differentiate between normal and abnormal findings in a nutritional assessment.
  • Differentiate normal from abnormal findings in the assessment of the skin, head, and neck.

2

Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual functioning. (PO #1)

Weekly Objectives

  • Examine how developmental stages affect your assessment of physical, psychosocial, cultural, and spiritual functioning.
  • Demonstrate normal from abnormal findings in the comprehensive assessment of the older adult.
  • Identify anatomical, developmental, psychosocial, and cultural variations that guide assessment of the skin, head, and neck.
  • Describe the skills and techniques required to assess the skin, head, and neck and document findings.

3

Utilize effective communication when performing a health assessment. (PO #3)

Weekly Objectives

  • Examine questions to be used when completing a focused interview for the skin, head, and neck.
  • Examine questions to be used when completing a focused interview related to an individual’s nutritional status.

4

Identify teaching/learning needs from the health history of an individual. (PO #2)

Weekly Objectives

  • Discuss the focus areas related to overall health of the skin, head, and neck in Healthy People 2020 initiatives.
  • Discuss the focus areas related to overall nutritional health in Healthy People 2020 initiatives.

5

Explore the professional responsibilities involved in conducting a comprehensive health assessment and provide appropriate documentation. (PO #6)

Weekly Objectives

  • Describe how the assessment of the integumentary system and nutritional status fits into the comprehensive health assessment and the associated documentation.

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observing our patients during first encounter

observing our patients during first encounter

 

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