NurseReview.Org - Introduction To Physical Assessment

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NurseReview.Org - Introduction To Physical Assessment

  1. 1. Introduction Physical Examination Health Assessment
  2. 2. Why do I need to know Physical Assessment?
  3. 4. “ What is your reason for coming here today?”
  4. 5. Assessment <ul><li>Collection of data about an individual’s health state. </li></ul>
  5. 6. <ul><li>Subjective Data </li></ul><ul><ul><li>Client history </li></ul></ul><ul><li>Objective Data </li></ul><ul><ul><li>Inspection </li></ul></ul><ul><ul><li>Percussion </li></ul></ul><ul><ul><li>Palpation </li></ul></ul><ul><ul><li>Auscultation </li></ul></ul>
  6. 7. Data Base <ul><li>All the information; obj., subjective, client’s record, lab, and test results </li></ul><ul><li>Study and cluster data </li></ul><ul><li>Diagnosis </li></ul><ul><li>Purpose of assessment is to make a diagnosis or judgement </li></ul>
  7. 8. Nursing Process <ul><li>ADPIE </li></ul><ul><ul><li>Assessment </li></ul></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>(outcome identification) </li></ul></ul><ul><ul><li>Planning </li></ul></ul><ul><ul><li>Implementation </li></ul></ul><ul><ul><li>Evaluation </li></ul></ul>
  8. 9. Critical Thinking <ul><li>Problem solving – the puzzle – the big picture </li></ul><ul><li>Processing information – use theory learned, experience, intuition, intellectual and manual skills </li></ul>
  9. 10. Priority Setting <ul><li>First level problems </li></ul><ul><ul><li>ABC’s </li></ul></ul><ul><ul><li>Vital Signs </li></ul></ul><ul><li>Second Level </li></ul><ul><ul><li>Mental Status changes (LOC) </li></ul></ul><ul><ul><li>Acute pain </li></ul></ul><ul><ul><li>Acute urinary elimination </li></ul></ul><ul><ul><li>Untreated medical problems </li></ul></ul><ul><ul><li>Abn. Bld. Values </li></ul></ul><ul><ul><li>Risks of infection, safety, security </li></ul></ul>
  10. 11. <ul><li>Third Level Priority </li></ul><ul><ul><li>Knowledge deficit </li></ul></ul><ul><ul><li>Activity, rest </li></ul></ul><ul><ul><li>Coping </li></ul></ul>
  11. 12. 4 Types of Data Base <ul><li>Complete ( Total ) </li></ul><ul><li>Episodic or Problem Centered </li></ul><ul><li>Follow – up </li></ul><ul><li>Emergency </li></ul>
  12. 13. Consideration of: <ul><li>Developmental States </li></ul><ul><li>Cultural Assessment </li></ul><ul><ul><li>Beliefs, values, practices </li></ul></ul>
  13. 14. The Interview <ul><li>“Spend more time listening” </li></ul><ul><li>Open /Closed ended questions </li></ul><ul><li>Interpreter </li></ul><ul><ul><li>Family/ professional </li></ul></ul>
  14. 15. Communication Skills <ul><li>Collecting information with understanding </li></ul><ul><li>Verbal/Nonverbal </li></ul>
  15. 16. Factors that impact on Communication <ul><li>Internal </li></ul><ul><ul><li>Personal attributes – acceptance of client (Nonjudgemental) </li></ul></ul><ul><ul><li>Respect </li></ul></ul><ul><ul><li>Empathy </li></ul></ul><ul><ul><li>Listening </li></ul></ul>
  16. 17. Factors that impact on Communication <ul><li>External Factors </li></ul><ul><ul><li>Privacy </li></ul></ul><ul><ul><li>Interruptions </li></ul></ul><ul><ul><li>Comfortable environment – temp., noise, lunch, bloody mess </li></ul></ul>
  17. 18. 10 Traps of Inteviewing pg 57 <ul><li>False Assurance </li></ul><ul><li>Unwanted Advice </li></ul><ul><li>Using Authority </li></ul><ul><li>Avoidance language – dead is dead </li></ul><ul><li>Engaging in distance “the Friend” </li></ul><ul><li>Professional jargon </li></ul><ul><li>Leading or biased questions; “you don’t…?” </li></ul>
  18. 19. <ul><li>Too much talking </li></ul><ul><li>Interrupting </li></ul><ul><li>Why? </li></ul>
  19. 20. Threat of Violence!!!! <ul><li>CPI training </li></ul>

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