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N 295 lecture 1 student copy N 295 lecture 1 student copy Presentation Transcript

  • HEALTH ASSESSMENT in NURSING N 295 Spring 2012 Revised january 2012
  • ASSESSMENT *
    • WHAT
    • HOW
    • WHY
    • WHERE
    • WHEN
    Revised january 2012
  • Sources of Data *
    • Primary Source
    • Secondary Source
    Revised january 2012
  • Data Collection Methods *
    • OBSERVATION
    • INTERVIEW
    • PHYSICAL EXAMINATION
    Revised january 2012
  • “ Why” Leads to Type of Assessment *
    • CONTINUOUS ?
    • ? SCREENING
    • ! follow-up ??
    • ¿ INTERMITTENT ?
    • !!? Emergency!!
    • ¿ COMPREHENSIVE
    • ..? Functional ¿
    • FOCUSED ? ¿
    Revised january 2012
  • NURSING ASSESSMENT
    • VS
    • MEDICAL PHYSICAL EXAMINATION
    Revised january 2012
  • Steps to Assessment
    • 1.
    • 2.
    • 3.
    • 4.
    Revised january 2012
  • Instead: Talk about PARTS of Assessment *
    • 1. Subjective Data Collection
    • 2. Objective Data Collection
    • 3. Validation of Data
    • 4. Documentation of Data
    Revised january 2012
  • Subjective Data
    • Where do you get this?
    • How do you get this information?
    • Sending and Receiving
    • Does It Require Skill to obtain data??
    Revised january 2012
  • Subjective Data *
    • Sign or Symptom?
    • Recognize that all behavior has meaning
    • Accept the client but set limits on inappropriate behavior
    Revised january 2012
    • What do you think?
    • Identify and face problems honestly
    • It is best to maintain
    • a professional distance
    Revised january 2012
  • COMMUNICATION in the INTERVIEW
    • *
    • Internal Factors
    • External Factors
    Revised january 2012
  • INTERVIEW TECHNIQUES
    • Verbal Communication
    • Non-Verbal Communication
    Revised january 2012
  • Cultural / Diversity Considerations
    • Language Barriers
    • Space, Distance & Intimacy Concepts
    • Variations in Response to Illness
    • Variation in Non-Verbal Behaviors
    Revised january 2012
  • Other Challenging Situations
    • Anxious Client
    • Angry Client
    • Depressed Client
    • Manipulative Client
    • Client with Sensitive Issues
    • Special Situations
    Revised january 2012
  • Complete Health History
    • Biographic Data
    • Reason for Seeking Health Care
    • History of Present Illness
    • IF there is an HPI . . .
    • . . .then do PQRST
    • If pain use PQRST or COLDSPA
    Revised january 2012
  • EXPLORING S & S Revised january 2012 P recipitating / Palliative Factors Q uality / Quantity R egion / Radiation / Related Symptoms S everity T iming
  • EXPLORING S & S
    • C Character
    • O Onset
    • L Location
    • D Duration
    • S Severity
    • P Pattern
    • A Associated symptoms
    Revised january 2012
  • Complete Health History *
    • Biographic Data
    • Reason for seeking Health Care
    • History of Present Illness
    • Past Health History
    • Family History
    • Review Of Systems
    • ADL & IADL
    • Lifestyle & Health Practice Profile
    • Developmental Level
    Revised january 2012
  • Revised january 2012