Introduction Physical Examination Health Assessment

Why do I need to know Physical Assessment?

“ What is your reason for coming here today?”

Assessment Collection of data about an individual’s health state.

Collection of data about an individual’s health state.

Subjective Data Client history Objective Data Inspection Percussion Palpation Auscultation

Subjective Data

Client history

Objective Data

Inspection

Percussion

Palpation

Auscultation

Data Base All the information; obj., subjective, client’s record, lab, and test results Study and cluster data Diagnosis Purpose of assessment is to make a diagnosis or judgement

All the information; obj., subjective, client’s record, lab, and test results

Study and cluster data

Diagnosis

Purpose of assessment is to make a diagnosis or judgement

Nursing Process ADPIE Assessment Diagnosis (outcome identification) Planning Implementation Evaluation

ADPIE

Assessment

Diagnosis

(outcome identification)

Planning

Implementation

Evaluation

Critical Thinking Problem solving – the puzzle – the big picture Processing information – use theory learned, experience, intuition, intellectual and manual skills

Problem solving – the puzzle – the big picture

Processing information – use theory learned, experience, intuition, intellectual and manual skills

Priority Setting First level problems ABC’s Vital Signs Second Level Mental Status changes (LOC) Acute pain Acute urinary elimination Untreated medical problems Abn. Bld. Values Risks of infection, safety, security

First level problems

ABC’s

Vital Signs

Second Level

Mental Status changes (LOC)

Acute pain

Acute urinary elimination

Untreated medical problems

Abn. Bld. Values

Risks of infection, safety, security

Third Level Priority Knowledge deficit Activity, rest Coping

Third Level Priority

Knowledge deficit

Activity, rest

Coping

4 Types of Data Base Complete ( Total ) Episodic or Problem Centered Follow – up Emergency

Complete ( Total )

Episodic or Problem Centered

Follow – up

Emergency

Consideration of: Developmental States Cultural Assessment Beliefs, values, practices

Developmental States

Cultural Assessment

Beliefs, values, practices

The Interview “Spend more time listening” Open /Closed ended questions Interpreter Family/ professional

“Spend more time listening”

Open /Closed ended questions

Interpreter

Family/ professional

Communication Skills Collecting information with understanding Verbal/Nonverbal

Collecting information with understanding

Verbal/Nonverbal

Factors that impact on Communication Internal Personal attributes – acceptance of client (Nonjudgemental) Respect Empathy Listening

Internal

Personal attributes – acceptance of client (Nonjudgemental)

Respect

Empathy

Listening

Factors that impact on Communication External Factors Privacy Interruptions Comfortable environment – temp., noise, lunch, bloody mess

External Factors

Privacy

Interruptions

Comfortable environment – temp., noise, lunch, bloody mess

10 Traps of Inteviewing pg 57 False Assurance Unwanted Advice Using Authority Avoidance language – dead is dead Engaging in distance “the Friend” Professional jargon Leading or biased questions; “you don’t…?”

False Assurance

Unwanted Advice

Using Authority

Avoidance language – dead is dead

Engaging in distance “the Friend”

Professional jargon

Leading or biased questions; “you don’t…?”

Too much talking Interrupting Why?

Too much talking

Interrupting

Why?

Threat of Violence!!!! CPI training

CPI training