NSG 2317 Lecture Notes - Lecture 1: Psoriasis, Tinnitus, Memory Disorder
Document Summary
Patient trajectory: patient trajectory: a health trajectory describes the dynamic (changing) course of health and illness, health issue manifestation, data collection, history, examination. Adpie (p. 1-5) (p. 10: assessment, diagnosis, planning, evaluation. Immediately life threatening: require prompt intervention to prevent deterioration. Important, but no threat of imminent or short-term harm: s: subjective (what the patient tells you, o: objective (what you observe, a: assessment (the actual assessment, p: plan (the plan you propose) Communicating assessment findings -sbar: a structured communication technique used to standardize communication and prevent misunderstandings. What are you calling about?: b: background (state the data pertinent to this moments problem, ex: admitting diagnosis, appropriate assessment data, vital signs, a: assessment (what do you think is happening right now?, r: recommendation. Interview (health hx: definition: collection of subjective data, can be whole or focused, purpose: Identifies health issues and strengths: guides physical exam, basis of most nursing/medical care.