00:02
Now, another way that we gather
information, is of course,
let's look at those
next assessment steps.
00:08
So physical examination gives
us so much information, guys.
00:12
Now, how do we assess?
If you remember,
there's that inspection,
where we palpate or percuss.
00:18
We listen by auscultation.
00:21
This is going to collect
valuable objective information.
00:25
Again, guys, I can't stress
physical examination enough.
00:29
If we don't physically or
do a head to toe assessment
on our patient,
we don't have tangible information
on our patient's condition.
00:38
Also, if you don't do a thorough
head to toe assessment,
or physical examination,
there may be
important key pieces
that we're missing
in that assessment phase.
00:48
It's also important
when we're examining
or taking care of our patient,
look at that verbal versus
nonverbal information
your patient gives you.
00:56
Look at their behavior.
00:58
So this is going to help us
gather information.
01:01
Here's a great example of this.
01:03
I have my patients
do this all the time.
01:06
I'll go into my
patient's room and say,
"Hey, Mr. Jones,
are you having any pain right now?"
And they're like,
"No, I'm not having any pain."
But then when I watch them,
they may be grimacing,
they may be really restless,
they've just had surgery.
01:19
When they get up to the bathroom,
they're limping,
they're really uncomfortable.
01:23
As you can see, the person's verbal
versus their nonverbal behavior
didn't match, right?
So as a nurse,
I need to be cognizant of this
and make sure I take that
into account as well.
01:37
Now, this is a little bit
more difficult.
01:39
And this comes a little bit more
with experience as a nurse.
01:43
So taking that
diagnostic information,
this is going to give us
additional supportive information
in that plan of care.
01:52
This also may change
our treatment for a patient.
01:55
What I'm talking about is maybe
a critical lab value, for example.
01:59
Let's say your patient has
a really high potassium
that's important
that we treat, right?
Also, this may be something might
change with like a chest X-ray,
if we have brand new results.
02:10
This is also important to include
all that diagnostic information
with your physical assessment,
with for the clinical picture
of your patient.
02:20
And then lastly,
interpreting and validating that
assessment data is really important.
02:25
So using all of this information,
such as
your assessment,
maybe labs and diagnostics,
your patient behavior,
this is all going to take,
all going to be really important
to help drive what
our priority problem
or maybe
our nursing diagnosis.
02:43
Also important
that we cluster this data
and look for patterns or trends
to compare them with
normal or abnormal standards.
02:53
Now let's talk about
assessment data
and data documentation.
02:58
Guys, this is such
an important piece
because as you know,
if it wasn't documented,
it wasn't done.
03:04
The reason why we talk about this
is if I'm a new nurse
coming on this shift,
and there's other information
that wasn't documented previously,
I don't know if this is
the trend of the patient.
03:16
Is this normal?
Is this abnormal?
That definitely affects
the continuity of care.
03:22
Also, don't forget the client record
is a legal document.
03:27
So it's really critical that we use
accurate and approved terminology.
03:31
Here's what I mean by this.
03:33
If we're using
just random terminology
that we make up ourselves,
you can imagine by
if someone reviews that
probably isn't the most
credible source
when you review
this documentation.
03:46
If it's not accurate,
or if it's just random
made up terminology
that's documented
in the patient's record.
03:53
And this must be completed
within a timely manner.
03:56
So I really encourage you
that as soon as you do something,
if you can, document it.
04:02
Reason being,
is many times we'll forget details
that are really important
to the patient's record,
if we don't document
within a timely manner.