NurseReview.Org - Introduction To Physical Assessment

Slide 1: Introduction Physical Examination Health Assessment

Slide 2: Why do I need to know Physical Assessment?

Slide 4: “What is your reason for coming here today?”

Slide 5: Assessment  Collection of data about an individual’s health state.

Slide 6:  Subjective Data  Client history  Objective Data  Inspection  Percussion  Palpation  Auscultation

Slide 7: 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

Slide 8: Nursing Process  ADPIE  Assessment  Diagnosis  (outcome identification)  Planning  Implementation  Evaluation

Slide 9: Critical Thinking  Problem solving – the puzzle – the big picture  Processing information – use theory learned, experience, intuition, intellectual and manual skills

Slide 10: 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

Slide 11:  Third Level Priority  Knowledge deficit  Activity, rest  Coping

Slide 12: 4 Types of Data Base 1. Complete ( Total ) 2. Episodic or Problem Centered 3. Follow – up 4. Emergency

Slide 13: Consideration of:  Developmental States  Cultural Assessment  Beliefs, values, practices

Slide 14: The Interview  “Spend more time listening”  Open /Closed ended questions  Interpreter  Family/ professional

Slide 15: Communication Skills  Collecting information with understanding  Verbal/Nonverbal

Slide 16: Factors that impact on Communication  Internal  Personal attributes – acceptance of client (Nonjudgemental)  Respect  Empathy  Listening

Slide 17: Factors that impact on Communication  External Factors  Privacy  Interruptions  Comfortable environment – temp., noise, lunch, bloody mess

Slide 18: 10 Traps of Inteviewing pg 57 1. False Assurance 2. Unwanted Advice 3. Using Authority 4. Avoidance language – dead is dead 5. Engaging in distance “the Friend” 6. Professional jargon 7. Leading or biased questions; “you don’t…?”

Slide 19: 1. Too much talking 2. Interrupting 3. Why?

Slide 20: Threat of Violence!!!!  CPI training