Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide As the nurse documents a physical assessment, these terms of location must be used so that anyone reading the documentation will have a very clear understanding of the exact location of the nurse’s findings. o Cranial: Towards the head o Caudal: Towards the feet o Right: On the patient's right side of the body o Left: On the patient's left side of the body o Proximal: Closest to the point where the appendage joins the body o Distal: Furthest from the point where the appendage joins the body o Medial: Toward the middle o Lateral: Toward the side o Anterior: Toward the front of the body o Posterior: Toward the rear of the body o Superior: Above another structure o Inferior: Below another structure o Dorsal: Toward the back of the body o Ventral: Toward the front of the body o Plantar: Pertaining to the sole of the foot o Palmar: Pertaining to the palm of the hand Experienced clinicians will perform each physical assessment in approximately the same order every time. This consistencywill ensure that relevant information is not forgotten. Often, the clinician will perform an assessment from the top of the head to the feet; hence, the term “head to toe assessment.” • The psychosocial assessment: Often overlooked, the psychosocial assessment will provide information about the patient’s psychological health and available support systems. Some of the areas to assess and document include: o Self-esteem: Does the patient make eye contact? Are they well groomed? o Affect: How does the patient’s mood seem to be? Happy? Sad? Flat (that is, there does not seem to be any mood at all)? Euphoric? Appropriate or inappropriate for the situation? o Energy level: Does the patient or family report decreased activity levels? o Support systems: Does the patient have family or friends he can count on? Are they experiencing any crises or stress in the family situation? o Living arrangements: Does the patient live alone, or is there someone in the home who can help with care? Does the patient live in some other living arrangement (assisted living, nursing home, etc.)? o Needs: What does the patient perceives as his or her needs? These may be very different than what the nurse thinks the patient needs. o Goals: What does the patient perceive as his or her goals? Note that these should be documented by the nurse, but may require further development by the team, since the patient’s goals may not be realistic.

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