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Definition/Introduction

The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected. Critical thinking skills applied during the nursing process provide a decision-making framework to develop and guide a plan of care for the patient incorporating evidence-based practice concepts. This concept of precision education to tailor care based on an individual's unique cultural, spiritual, and physical needs, rather than a trial by error, one size fits all approach results in a more favorable outcome.[1][2][3]

Nội dung chính
    Definition/IntroductionIssues of ConcernClinical SignificanceWhich position is usually recommended when the nurse is assessing a patient's heart and lungs select all that apply?Why is it important for the client to change positions during the assessment of the heart?Which position is the most suitable for an abdominal examination?Which of the following position is most appropriate for a patient having a breast examination?

The nursing assessment includes gathering information concerning the patient's individual physiological, psychological, sociological, and spiritual needs. It is the first step in the successful evaluation of a patient. Subjective and objective data collection are an integral part of this process. Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using an age or condition appropriate pain scale. The assessment identifies current and future care needs of the patient by allowing the formation of a nursing diagnosis. The nurse recognizes normal and abnormal patient physiology and helps prioritize interventions and care.[4][5]

 Nursing Process

    Assessment (gather subjective and objective data, family history, surgical history, medical history, medication history, psychosocial history)

    Analysis or diagnosis (formulate a nursing diagnosis by using clinical judgment; what is wrong with the patient)

    Planning (develop a care plan which incorporates goals, potential outcomes, interventions)

    Implementation (perform the task or intervention)

    Evaluation (was the intervention successful or unsuccessful)

Issues of Concern

The function of the initial nursing assessment is to identify the assessment parameters and responsibilities needed to plan and deliver appropriate, individualized care to the patient.[6][7][8][9]

This includes documenting:

    Appropriate level of care to meet the client's or patient’s needs in a linguistically appropriate, culturally competent manner

    Evaluating response to care

    Community support

    Assessment and reassessment once admitted

    Safe plan of discharge

The nurse should strive to complete:

    Admission history and physical assessment as soon as the patient arrives the unit or status is changed to an inpatient

    Data collected should be entered on the Nursing Admission Assessment Sheet and may vary slightly depending on the facility

    Additional data collected should be added

    Documentation and signature either written or electronic by the nurse performing the assessment

Summary Nursing Admission Assessment

Documentation: Name, medical record number, age, date, time, probable medical diagnosis, chief complaint, the source of information (two patient identifiers)

Past medical history: Prior hospitalizations and major illnesses and surgeries

Assess pain: Location, severity, and use of a pain scale

Allergies: Medications, foods, and environmental; nature of the reaction and seriousness; intolerances to medications; apply allergy band and confirm all prepopulated allergies in the electronic medical record (EMR) with the patient or caregiver

Medications: Confirm accuracy of the list, names, and dosages of medications by reconciling all medications promptly using electronic data confirmation, if available, from local pharmacies; include supplements and over-the-counter medications

Valuables: Record and send to appropriate safe storage or send home with family following any institutional policies on the secure management of patient belongings; provide and label denture cups

Rights: Orient patient, caregivers, and family to location, rights, and responsibilities; goal of admission and discharge goal

Activities: Check daily activity limits and need for mobility aids

Falls: Assess Morse Fall Risk and initiate fall precautions as dictated by institutional policy

Psychosocial: Evaluate need for a sitter or video monitoring, any signs of agitation, restlessness, hallucinations, depression, suicidal ideations, or substance abuse

Nutritional: Appetite, changes in body toàn thân weight, need for nutritional consultation based on body toàn thân mass index (BMI) calculated from measured height and weight on admission

Vital signs: Temperature recorded in Celsius, heart rate, respiratory rate, blood pressure, pain level on admission, oxygen saturation

Any handoff information from other departments

Physical Exam

    Cardiovascular: Heart sounds; pulse irregular, regular, weak, thready, bounding, absent; extremity coolness; capillary refill delayed or brisk; presence of swelling, edema, or cyanosis

    Respiratory: Breath sounds, breathing pattern, cough, character of sputum, shallow or labored respirations, agonal breathing, gasps, retractions present, shallow, asymmetrical chest rise, dyspnea on exertion

    Gastrointestinal: Bowel sounds, abdominal tenderness, any masses, scars, character of bowel movements, color, consistency, appetite poor or good, weight loss, weight gain, nausea, vomiting, abdominal pain, presence of feeding tube

    Genitourinary: Character of voiding, discharge, vaginal bleeding (pad count), last menstrual period or date of menopause or hysterectomy, rashes, itching, burning, painful intercourse, urinary frequency, hesitancy, presence of catheter

    Neuromuscular: Level of consciousness using AVPU (alert, voice, pain, unresponsive); Glasgow coma scale (GCS); speech clear, slurred, or difficult; pupil reactivity and appearance; extremity movement equal or unequal; steady gait; trouble swallowing

    Integument: Turgor, integrity, color, and temperature, Braden Risk Assessment, diaphoresis, cold, warm, flushed, mottled, jaundiced, cyanotic, pale, ruddy, any signs of skin breakdown, chronic wounds

Initial Assessment[10][11][12]

Steps in Evaluating a New Patient

    Record chief complaint and history

    Perform physical examination

    Complete an initial psychological evaluation; screen for intimate partner violence; CAGE questionnaire and CIWA (Clinical Institute Withdrawal Assessment for Alcohol) scoring if indicated; suicide risk assessment

    Provide a certified translator if a language barrier exists; ensure culturally competent care and privacy

    Ensure the healthcare provider has ordered the appropriate tests for the suspected diagnosis, and initiate any predetermined protocols according to the hospital or institutional policy

Which provides the diagnosis most often: history, physical, or diagnostic tests?

    History: 70%

    Physical: 15% to 20%

    Diagnostic tests: 10% to 15%

History Taking Techniques

Record chief complaint

History of the present illness, presence of pain

P-Q.-R-S-T Tool to Evaluate Pain

    P: What provokes symptoms? What improves or exacerbates the condition? What were you doing when it started? Does position or activity make it worse?

    Q.: Quality and Quantity of symptoms: Is it dull, sharp, constant, intermittent, throbbing, pulsating, aching, tearing or stabbing?

    R: Radiation or Region of symptoms: Does the pain travel, or is it only in one location? Has it always been in the same area, or did it start somewhere else?

    S: Severity of symptoms or rating on a pain scale. Does it affect activities of daily living such as walking, sitting, eating, or sleeping?

    T: Time or how long have they had the symptoms. Is it worse after eating, changes in weather, or time of day?

S-A-M-P-L-E

    S: Signs and symptoms

    A: Allergies

    M: Medications

    P: Past medical history

    L: Last meal or oral intake

    E: Events before the acute situation

Pain Assessment

Pain, or the fifth vital sign, is a crucial component in providing the appropriate care to the patient. Pain assessment may be subjective and difficult to measure. Pain is anything the patient or client states that it is to them. As nurses, you should be aware of the many factors that can influence the patient's pain. Systematic pain assessment, measurement, and reassessment enhance the ability to keep the patient comfortable. Pain scales that are age appropriate assist in the concise measurement and communication of pain among providers. Improvement of communication regarding pain assessment and reassessment during admission and discharge processes facilitate pain management, thus enhancing overall function and quality of life in a trickle-down fashion.

According to one performance and improvement outpatient project in 2022, areas for improvement in pain reassessment policies and procedures were identified in a clinic setting. The study concluded compliance rates for the 30-minute time requirement outlined in the clinic policy for pain reassessment were found to be low. Heavy patient load, staff memory rather than documentation, and a lack of standardized procedures in the electronic health record (EHR) design played a role in low compliance with the reassessment of pain. Barriers to pain assessment and reassessment are important benchmarks in quality improvement projects. Key performance indicators (KPIs) to improve pain management goals and overall patient satisfaction, balanced with the challenges of an opioid crisis and oversedation risks, all play a role in future research studies and quality of care projects. Recognition of indicators of pain and comprehensive knowledge in pain assessment will guide care and pain management protocols.

Indicators of Pain

    Restlessness or pacing

    Groaning or moaning

    Crying

    Gasping or grunting

    Nausea or vomiting

    Diaphoresis

    Clenching of the teeth and facial expressions

    Tachycardia or blood pressure changes

    Panting or increased respiratory rate

    Clutching or protecting a part of the body toàn thân

    Unable to speak or open eyes

    Decreased interest in activities, social gatherings, or old routines

Psychosocial Assessment

The primary consideration is the health and emotional needs of the patient. Assessment of cognitive function, checking for hallucinations and delusions, evaluating concentration levels, and inquiring into interests and level of activity constitute a mental or emotional health assessment. Asking about how the client feels and their response to those feelings is part of a psychological assessment. Are they agitated, irritable, speaking in loud vocal tones, demanding, depressed, suicidal, unable to talk, have a flat affect, crying, overwhelmed, or are there any signs of substance abuse? The psychological examination may include perceptions, whether justifiable or not, on the part of the patient or client. Religion and cultural beliefs are critical areas to consider. Screening for delirium is essential because symptoms are often subtle and easily overlooked, or explained away as fatigue or depression.

Safety Assessment

    Ambulatory aids

    Environmental concerns, home safety

    Domestic and family violence risk, human trafficking risks, elder or child abuse risk

    Fall risk

    Suicidal ideation (initiate suicide precautions as directed by institutional policy)

Therapeutic Communication Techniques Used to Take a Good History

Multiple strategies are employed that will include:

    Active, attentive listening

    Reflection, sharing observations

    Empathy

    Share hope 

    Share humor

    Touch

    Therapeutic silence

    Provide information

    Clarification

    Focusing

    Paraphrasing

    Asking relevant questions

    Summarizing

    Self-disclosure

    Confrontation

What are examples?

    Active, attentive listening: Attention to the details of what the patient is saying either in a verbal or nonverbal manner

    Reflection, share observations: Repeat the patient’s words to encourage discussion, state observations that will not make the patient angry or embarrassed; i.e., " You seem tired today, sad...," " You have hardly eaten anything this morning."

    Empathy: Demonstrate that you understand and feel for the patient, recognition of their current situation and perceived feelings, and communicating in a nonjudgmental, unbiased way of acceptance

    Share hope: Ensure in the patient a sense of power, hope in an often hopeless environment, and the possibility of a positive outcome

    Share humor: Fosters a relationship of emotional support, establishes rapport, acts as a positive diversion technique, and promotes physical and mental well being. Cultural considerations play a role in humor

    Touch: Touch may be a source of comfort or discomfort for a patient, wanted or unwanted; observe verbal and nonverbal cues with touch; holding a hand, conducting a physical assessment, performing a procedure

    Therapeutic silence: Fosters an environment of patience, thought and reflection on difficult decisions, and allows time to observe any nonverbal signs of discomfort (the patient typically breaks the silence first)

    Provide information: During an assessment and care, inform the patient as to what is about to happen, explain findings and the need for further testing or observation to promote trust and decrease anxiety

    Clarification: Ask questions to clear up ambiguous statements, ask the client or patient to rephrase or restate confusing remarks so wrong assumptions are clarifiable and a missed opportunity for valuable information forgone

    Focusing: Brings the focus of the conversation to an essential area of concern, eliminating vague or rambling dialogue, centers the assessment on the source of discomfort and pertinent details in the history

    Paraphrasing: Invites patient participation and understanding in a conversation

    Asking relevant questions: Questions are general first then become more specific; asked in a logical, consecutive order; open-ended, close-ended, and focused questions may be useful during an assessment

    Summarizing: Provides a review of assessment findings, offers clarification opportunities, informs the next step in the admission and hospitalization process

    Self-disclosure: Promotes a trusting relationship, the feeling that the patient is not in this alone, or unique in their current circumstances; provides a framework for hope, support, and respect

    Confrontation: You may have to confront the patient after a trustful rapport has been established, discussing any inconsistencies in the history, thought processes, or inappropriate behavior

Cultural Assessment

The cultural competency assessment will identify factors that may impede the implementation of nursing diagnosis and care. Information obtained should include:

    Ethnic origin, languages spoken, and need for an interpreter

    Primary language preferred for written and verbal instructions

    Support system, decision makers

    Living arrangements

    Religious practices

    Emotional responses

    Special food requirements, dietary considerations

    Cultural customs or taboos such as unwanted touching or eye contact

Physical Examination Techniques

Initial evaluation or the general survey may include:

    Stature

    Overall health status

    Body habitus

    Personal hygiene, grooming

    Skin condition such as signs of breakdown or chronic wounds

    Breath and body toàn thân odor

    Overall mood and psychological state

    Initial vital sign measurements: temperature recorded in Celsius in most institutions, respiratory rate, pulse rate, blood pressure with appropriate sized cuff, pulse oximetry reading and note if on room air or oxygen; accurately measured weight in kilograms with the proper scale and height measurement, so body toàn thân mass index (BMI) is calculable for dosing weights and nutritional guidelines

Secondary Assessment

    Cardiovascular

    Pulmonary

    Gastrointestinal

    Musculoskeletal

    Neurological

    Genitourinary/Pelvic

    Integumentary

    Mental status and behavioral

Techniques

Inspection

    Look all areas of the skin, including those under clothing or gowns

    Ensure patient is undressed, allowing for privacy, uncover one body toàn thân part a time if possible

    Lighting should be bright

    Be alert for any malodors from the body toàn thân including the oral cavity; fecal odor, fruity-smell, odor of alcohol or tobacco on the breath

    Compare one side to the other, and ask the patient about any asymmetrical areas

    Observe for color, rashes, skin breakdown, tubes and drains, scars, bruising, burns

    Grade any edema present

    Document pertinent normal and abnormal findings

Palpation

    Texture

    Size

    Consistency

    Crepitus

    Any masses

    Turgor

    Tenderness 

    Temperature and moisture (warm, moist or cool, and dry)

    Distention

    Tactile fremitus

Percussion

    Good hand and finger technique

    Good striking and listening technique

    Especially important in the pulmonary and gastrointestinal systems

    Dull, flat, resonance, hyper-resonance, or tympany sounds

    Percussion is an advanced technique requiring a specific skill set to perform. Therefore, it is a skill practiced by advanced practice nurses as opposed to a bedside nurse on a routine basis

Auscultation

    Listening to body toàn thân sounds such as bowel sounds, breath sounds, and heart sounds

    Important in examination of the heart, blood pressure, and gastrointestinal system

    Listen for bruits, murmurs, friction rubs, and irregularities in pulse

What are important things to remember about the physical exam?

    Physical exam length can vary depending on complexity

    Physical exam extends from passive observation to hands-on 

    Be systematic and thorough

    Ensure privacy and comfort

    Warm hands for patient comfort

    Avoid long fingernails to prevent patient injury during the exam

    Palpate areas that are tender or painful last

    Be alert for any signs of maltreatment or abuse, and follow mandatory reporting guidelines

    Abdominal assessment follows the techniques in this sequence: inspection, auscultation, percussion, and palpation

    Auscultate bowel sounds for least 15 seconds in each quadrant using the diaphragm of the stethoscope, starting with the lower right-hand quadrant and moving clockwise

    If a fistula is present for hemodialysis, assess for a thrill or bruit, document presence or absence. Notify managing healthcare provider immediately if absent

    Steps in a comprehensive lung exam include PIPPA; Positioning of the patient, Inspection, Palpation, Percussion, Auscultation

Diagnostic Studies

Driven by findings on the history and physical examination; options include:

    Blood tests (CBC, chemistry, bedside glucose, pregnancy test, urinalysis, cardiac enzymes, coagulation studies)

    Imaging studies (X-rays, CT, MRI, ultrasound)

    Other diagnostic studies (ECG, EEG, lumbar puncture, etc.,)

Discharge Planning

    Document mode of transport

    Who is accompanying the patient?

    Transfer forms/EMTALA considerations

    Functional status

    Financial considerations

    Discharge medications and instructions

    Follow up information, referrals, hotline numbers, shelter information

    Barriers to learning

    Document verbalization that discharge instructions were understood by caregiver or surrogate

    Provide translators and language appropriate discharge instructions or paperwork

Clinical Significance

Often the initial history and physical examination lead to the identification of life- or limb-threatening conditions that can be stabilized promptly, ensuring better patient outcomes. The sooner the patient is correctly assessed, the more likely a life-altering condition is recognizable, nursing diagnosis formulated, appropriate intervention or treatment initiated, and stabilizing care rendered. Physiological abnormalities manifested by changes in vital signs and level of consciousness often provide early warning signs that patient condition is deteriorating; thus, requiring prompt intervention to forego an adverse outcome, decreasing morbidity and mortality risk. In the fast-paced, resource-challenged healthcare environment today, thorough assessment can pose a challenge for the healthcare provider but is essential to safe, quality care. The importance of a head-to-toe assessment, critical thinking skills guided by research, and therapeutic communication are the mainstays of safe practice. [13][14][15]

Assessment findings that include current vital signs, lab values, changes in condition such as decreased urine output, cardiac rhythm, pain level, and mental status, as well as pertinent medical history with recommendations for care, are communicated to the provider by the nurse. Communicating in a concise, efficient manner in rapidly changing situations and deteriorating patient conditions can promote quick solutions during difficult circumstances. Healthcare providers communicate and share in the decision-making process. The SBAR model facilitates this communication between members of the healthcare team and bridges the gap between a narrative, descriptive approach and one armed with exact details.

Communication using the SBAR Model

    Situation

    Background

    Assessment

    Recommendation

Assessment Tools

    Activities of daily living scale

    Cough assessment

    Health questionnaires such as those that address recent travel and exposure risks

    Waterlow or Braden scale for assessing pressure ulcer risk

    Glasgow coma scale/AVPU for assessment of consciousness

    Pain scales such as the Faces Pain Scale (FPS), Numeric Rating System (NRS), Visual Analogue Scales (VAS), Wong-Baker Faces Pain Rating Scale (WBS), and the (MPQ) McGill Pain Questionnaire

    CAGE assessment/CIWA scoring

    Morse Fall Risk

    Standard vital sign flow charts for different age groups

    NIH Stroke Scale (NIHSS)

    Dysphagia Screen

    4AT Assessment for Delirium

Equipment

    The nurse should be familiar with the otoscope, penlight, stethoscope (bell and diaphragm), thermometer, bladder scanner, speculum, eye charts, cardiac and blood pressure monitors, fetal doppler and extremity doppler, and sphygmomanometer

    Stretcher or bed for proper positioning during a physical exam

    Hand hygiene products, personal protective equipment if required

    Alcohol swabs, sanitizer, or soapy water to clean equipment after use, such as with stethoscopes, to decrease the likelihood of cross-contamination of pathogens from inanimate objects (follow any manufacturer guidelines or institutional policies)

    Computer or paper chart to document findings

    Calculation devices for BMI, conversion from pounds to kilograms, kilograms to pounds, Celsius to Farenheight

References

1.

Dunham M, MacInnes J. Relationship of Multiple Attempts on an Admissions Examination to Early Program Performance. J Nurs Educ. 2022 Oct 01;57(10):578-583. [PubMed: 30277541]

2.

Allen E, Williams A, Jennings D, Stomski N, Goucke R, Toye C, Slatyer S, Clarke T, McCullough K. Revisiting the Pain Resource Nurse Role in Sustaining Evidence-Based Practice Changes for Pain Assessment and Management. Worldviews Evid Based Nurs. 2022 Oct;15(5):368-376. [PubMed: 30160011]

3.

Palmer RM. The Acute Care for Elders Unit Model of Care. Geriatrics (Basel). 2022 Sep 11;3(3) [PMC free article: PMC6319242] [PubMed: 31011096]

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Jamieson H, Abey-Nesbit R, Bergler U, Keeling S, Schluter PJ, Scrase R, Lacey C. Evaluating the Influence of Social Factors on Aged Residential Care Admission in a National trang chủ Care Assessment Database of Older Adults. J Am Med Dir Assoc. 2022 Nov;20(11):1419-1424. [PubMed: 30926408]

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Abdul-Kareem K, Lindo JLM, Stennett R. Medical-surgical nurses' documentation of client teaching and discharge planning a Jamaican hospital. Int Nurs Rev. 2022 Jun;66(2):191-198. [PubMed: 30734275]

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Gray LC, Beattie E, Boscart VM, Henderson A, Hornby-Turner YC, Hubbard RE, Wood S, Peel NM. Development and Testing of the interRAI Acute Care: A Standardized Assessment Administered by Nurses for Patients Admitted to Acute Care. Health Serv Insights. 2022;11:1178632918818836. [PMC free article: PMC6299328] [PubMed: 30618486]

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Joyce P, Moore ZE, Christie J. Organisation of health services for preventing and treating pressure ulcers. Cochrane Database Syst Rev. 2022 Dec 09;12:CD012132. [PMC free article: PMC6516850] [PubMed: 30536917]

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Cruz-Oliver DM, Abshire M, Cepeda O, Burhanna P, Johnson J, Velazquez DV, Chen J, Diab K, Christopher K, Rodin M. Adherence to Measuring What Matters: Description of an Inpatient Palliative Care Service of an Urban Teaching Hospital. J Palliat Med. 2022 Jan;22(1):75-79. [PubMed: 30129814]

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Blenke AA, van Marum RJ, Vermeulen Windsant-van den Tweel AM, Hermens WA, Derijks HJ. Deprescribing in Newly Admitted Psychogeriatric Nursing Facility Patients. Consult Pharm. 2022 Jun 01;33(6):331-338. [PubMed: 29880095]

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Rodziewicz TL, Houseman B, Hipskind JE. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 6, 2022. Medical Error Reduction and Prevention. [PubMed: 29763131]

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Long M, Farion KJ, Zemek R, Voskamp D, Barrowman N, Akiki S, Reid S. A nurse-initiated jaundice management protocol improves quality of care in the paediatric emergency department. Paediatr Child Health. 2022 Aug;22(5):259-263. [PMC free article: PMC5804750] [PubMed: 29479230]

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de Magalhães-Barbosa MC, Robaina JR, Prata-Barbosa A, Lopes CS. Validity of triage systems for paediatric emergency care: a systematic review. Emerg Med J. 2022 Nov;34(11):711-719. [PubMed: 28978650]

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Epstein AS, Desai AV, Bernal C, Romano D, Wan PJ, Okpako M, Anderson K, Chow K, Kramer D, Calderon C, Klimek VV, Rawlins-Duell R, Reidy DL, Goldberg JI, Cruz E, Nelson JE. Giving Voice to Patient Values Throughout Cancer: A Novel Nurse-Led Intervention. J Pain Symptom Manage. 2022 Jul;58(1):72-79.e2. [PMC free article: PMC6849206] [PubMed: 31034869]

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Prone positioning is generally used for patients who require a ventilator (breathing machine). Prone positioning may be beneficial for several reasons: (1) In the supine position, the lungs are compressed by the heart and abdominal organs.

Why is it important for the client to change positions during the assessment of the heart?

Each position brings the heart nearer to the chest wall, improving the sounds heard. Additional cardiac assessments should include the evaluation of the carotid arteries, jugular veins, and peripheral vessels.

Which position is the most suitable for an abdominal examination?

Abdominal examination is ideally performed with the patient in the supine position. The examiner should first observe the anxious patient and have him or her calm down enough to assess any evidence of tenderness prior to initiation of auscultation and palpation.

Which of the following position is most appropriate for a patient having a breast examination?

The breasts are best examined while lying down because it spreads the breast tissue evenly over the chest. Lie flat on your back, with one arm over your head and a pillow or folded towel under the shoulder. This position flattens the breast and makes it easier to check. Tải thêm tài liệu liên quan đến nội dung bài viết Which position is usually recommended when the nurse is assessing a patients heart and lungs select all that apply?

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