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HEALTH  ASSESSMENT  in  NURSING N 295  Spring 2012 Revised january 2012
ASSESSMENT  * <ul><li>WHAT  </li></ul><ul><li>HOW </li></ul><ul><li>WHY </li></ul><ul><li>WHERE </li></ul><ul><li>WHEN </l...
Sources of Data  * <ul><li>Primary Source </li></ul><ul><li>Secondary Source </li></ul>Revised january 2012
Data Collection Methods  * <ul><li>OBSERVATION </li></ul><ul><li>INTERVIEW </li></ul><ul><li>PHYSICAL EXAMINATION </li></u...
“ Why” Leads to Type of Assessment * <ul><li>CONTINUOUS  ?   </li></ul><ul><li>?  SCREENING </li></ul><ul><li>!  follow-up...
NURSING ASSESSMENT <ul><li>VS </li></ul><ul><li>MEDICAL PHYSICAL EXAMINATION </li></ul>Revised january 2012
Steps to Assessment <ul><li>1. </li></ul><ul><li>2. </li></ul><ul><li>3. </li></ul><ul><li>4. </li></ul>Revised january 2012
Instead:  Talk about  PARTS  of Assessment  * <ul><li>1.  Subjective Data Collection </li></ul><ul><li>2. Objective Data C...
Subjective Data  <ul><li>Where do you get this? </li></ul><ul><li>How do you get this information? </li></ul><ul><li>Sendi...
Subjective Data  * <ul><li>Sign or Symptom? </li></ul><ul><li>Recognize that all behavior has meaning </li></ul><ul><li>Ac...
<ul><li>What do you think? </li></ul><ul><li>Identify and face problems honestly </li></ul><ul><li>It is best to maintain ...
COMMUNICATION  in the INTERVIEW <ul><li>* </li></ul><ul><li>Internal Factors </li></ul><ul><li>External Factors </li></ul>...
INTERVIEW  TECHNIQUES <ul><li>Verbal Communication </li></ul><ul><li>Non-Verbal Communication </li></ul>Revised january 2012
Cultural / Diversity Considerations <ul><li>Language Barriers </li></ul><ul><li>Space, Distance & Intimacy Concepts </li><...
Other Challenging Situations <ul><li>Anxious Client </li></ul><ul><li>Angry Client </li></ul><ul><li>Depressed Client </li...
Complete Health History <ul><li>Biographic Data </li></ul><ul><li>Reason for Seeking Health Care </li></ul><ul><li>History...
EXPLORING S & S Revised january 2012 P recipitating / Palliative Factors Q uality / Quantity R egion / Radiation /  Relate...
EXPLORING S & S <ul><li>C  Character </li></ul><ul><li>O  Onset </li></ul><ul><li>L  Location </li></ul><ul><li>D  Duratio...
Complete Health History  * <ul><li>Biographic Data </li></ul><ul><li>Reason for seeking Health Care </li></ul><ul><li>Hist...
Revised january 2012
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N 295 lecture 1 student copy

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

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