Nursing assessment involves collecting data to understand a patient's health status. It includes gathering subjective information from the patient and objective data through examination. The nurse organizes, validates, and documents the assessment data to identify health problems, strengths, and needs to develop an appropriate plan of care. Common assessment techniques are inspection, palpation, percussion, and auscultation to examine each body system.
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
In this topic the student will be easily learn about how to collect history from the patient and also helpful nursing students to write their care plan and care study.
Back care consists of cleaning and massaging back (from shoulder to lower level of the buttocks) by using scientific form of required strokes for maximizing cutaneous stimulation, comfort and emotional relaxation as well.
In this topic the student will be easily learn about how to collect history from the patient and also helpful nursing students to write their care plan and care study.
Back care consists of cleaning and massaging back (from shoulder to lower level of the buttocks) by using scientific form of required strokes for maximizing cutaneous stimulation, comfort and emotional relaxation as well.
Health assessment By - Jitendra Bokha.pptxJitendra Bokha
Health assessment is defined as systematic and dynamic process by which nurse through interaction with client, significant others and health care providers, collect data about the client.
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
The first step for assessing a person's health and disease status. A detailed comprehension of health assessment can enable health care professionals to work more confidently in the clinical setting.
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
tHESE SLIDES ARE PREPAREED TO UNDERSTAND about HEALTH ASSESSMENT IN EASY WAY Important links- NOTES- https://mynursingstudents.blogspot.com/ youtube channel https://www.youtube.com/c/MYSTUDENTSU... CHANEL PLAYLIST- ANATOMY AND PHYSIOLOGY-https://www.youtube.com/playlist?list=PL93S13oM2gAPM3VTGVUXIeswKJ3XGaD2p COMMUNITY HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPyslPNdIJoVjiXEDTVEDzs CHILD HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gANcslmv0DXg6BWmWN359Gvg FIRST AID- https://www.youtube.com/playlist?list=PL93S13oM2gAMvGqeqH2ZTklzFAZhOrvgP HCM- https://www.youtube.com/playlist?list=PL93S13oM2gAM7mZ1vZhQBHWbdLnLb-cH9 FUNDAMENTALS OF NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPFxu78NDLpGPaxEmK1fTao COMMUNICABLE DISEASES- https://www.youtube.com/playlist?list=PL93S13oM2gAOWo4IwNjLU_LCuhRN0ZLeb ENVIRONMENTAL HEALTH- https://www.youtube.com/playlist?list=PL93S13oM2gAPkI6LvfS8Zu1nm6mZi9FK6 MSN- https://www.youtube.com/playlist?list=PL93S13oM2gAOdyoHnDLAoR_o8M6ccqYBm HINDI ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAN4L-FJ3s_IEXgZCijGUA1A ENGLISH ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAMYv2a1hFcq4W1nBjTnRkHP facebook profile- https://www.facebook.com/suresh.kr.lrhs/ FACEBOOK PAGE- https://www.facebook.com/My-Student-S... facebook group NURSING NOTES- https://www.facebook.com/groups/24139... FOR MAKING EASY NOTES YOU CAN ALSO VISIT MY BLOG – BLOGGER- https://mynursingstudents.blogspot.com/ Instagram- https://www.instagram.com/mystudentsu... Twitter- https://twitter.com/student_system?s=08 #PEM, #ASHA,#DIPHTHERIA,#ICDS,#nurses,#ASSESSMENT, #APPEARENCE,#PULSE,#GRIMACE,#REFLEX,#RESPIRATION,#RESUSCITATION,#NEWBORN,#BABY,#VIRGINIA, #CHILD, #OXYGEN,#CYANOSIS,#OPTICNERVE, #SARACHNA,#MYSTUDENTSUPPORTSYSTEM, #rashes,#nursingclasses, #communityhealthnursing,#ANM, #GNM, #BSCNURING,#NURSINGSTUDENTS, #WHO,#NURSINGINSTITUTION,#COLLEGEOFNURSING,#nursingofficer,#COMMUNITYHEALTHOFFICE
THESE SLIDES ARE PREPAREED TO UNDERSTAND about HEALTH ASSESSMENT- HISTORY TAKING IN EASY WAY Important links- NOTES- https://mynursingstudents.blogspot.com/ youtube channel https://www.youtube.com/c/MYSTUDENTSU... CHANEL PLAYLIST- ANATOMY AND PHYSIOLOGY-https://www.youtube.com/playlist?list=PL93S13oM2gAPM3VTGVUXIeswKJ3XGaD2p COMMUNITY HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPyslPNdIJoVjiXEDTVEDzs CHILD HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gANcslmv0DXg6BWmWN359Gvg FIRST AID- https://www.youtube.com/playlist?list=PL93S13oM2gAMvGqeqH2ZTklzFAZhOrvgP HCM- https://www.youtube.com/playlist?list=PL93S13oM2gAM7mZ1vZhQBHWbdLnLb-cH9 FUNDAMENTALS OF NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPFxu78NDLpGPaxEmK1fTao COMMUNICABLE DISEASES- https://www.youtube.com/playlist?list=PL93S13oM2gAOWo4IwNjLU_LCuhRN0ZLeb ENVIRONMENTAL HEALTH- https://www.youtube.com/playlist?list=PL93S13oM2gAPkI6LvfS8Zu1nm6mZi9FK6 MSN- https://www.youtube.com/playlist?list=PL93S13oM2gAOdyoHnDLAoR_o8M6ccqYBm HINDI ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAN4L-FJ3s_IEXgZCijGUA1A ENGLISH ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAMYv2a1hFcq4W1nBjTnRkHP facebook profile- https://www.facebook.com/suresh.kr.lrhs/ FACEBOOK PAGE- https://www.facebook.com/My-Student-S... facebook group NURSING NOTES- https://www.facebook.com/groups/24139... FOR MAKING EASY NOTES YOU CAN ALSO VISIT MY BLOG – BLOGGER- https://mynursingstudents.blogspot.com/ Instagram- https://www.instagram.com/mystudentsu... Twitter- https://twitter.com/student_system?s=08 #Physicalexamination,#historytaking,#communicablediseases,#ASSESSMENT, #APPEARENCE,#PULSE,#GRIMACE,#REFLEX,#RESPIRATION,#RESUSCITATION,#NEWBORN,#BABY,#VIRGINIA, #CHILD, #OXYGEN,#CYANOSIS,#OPTICNERVE, #SARACHNA,#MYSTUDENTSUPPORTSYSTEM, #rashes,#nursingclasses, #communityhealthnursing,#ANM, #GNM, #BSCNURING,#NURSINGSTUDENTS, #WHO,#NURSINGINSTITUTION,#COLLEGEOFNURSING,#nursingofficer,#COMMUNITYHEALTHOFFICE,#HEALTHPROBLEMS
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
2. INTRODUCTION
Assessment is the first step to determine health
status . It is the gathering of information to
have all the “necessary puzzle pieces ” to make
a clear picture of the person’s health status.
The entire plan of care is based on the data you
collect during this phase and make every effort
to ensure that your information is correct,
complete and organized in a way that you will
begin to get a sense of patterns of health or
illness.
3. DEFINITION OF ASSESSMENT
According to Carpenito :-Assessment is the
deliberate and systematic collection of data to
determine a client’s current and past health status
functional status and to determine the client’s
present and coping patterns.
Atkinson and murray(1991) :- Assessment is a
part of each activity the nurse does for and with
the patient.
4. PURPOSES OF ASSESSMENT
To gather information regarding client’s health.
To determine client’s normal function.
To organize the collected information.
To confirm hypothesis growing out of the nurse’s
interview.
To enhance investigation of nursing problems.
To frame nursing diagonsis.
It increases greater managing skill of handling
patient’s problem.
To identify the health problems.
To identify client’s strengths.
To identify need for health teaching.
6. INITIAL ASSESSMENT
It is performed within specified time after
admission to a health care agency.
Purpose : To establish a complete data base for
problem identification , reference , and future
comparison.
Ex :- Nursing admission assessment
7. FOCUS OR ONGOING
ASSESSMENT
Ongoing process integrated with nursing care.
Purpose : To determine the status of a specific
problem identified in an earlier assessment and
to identify new or overlooked problem.
Ex : Hourly assessment of client’s fluid intake
and output chart.
8. EMERGENCY ASSESSMENT
During any physiologic or psychologic crisis of the
client.
Purpose : To identify life-threatening problems.
Ex : A) Rapid assessment of person’s airway , breathing
status and circulation during a cardiac arrest.
B) Assessment of suicidal tendencies or potential for
violence.
9. TIME-LAPSED ASSESSMENT
Several months after initial assessment.
Purpose : To compare the client’s current status to
baseline data previously obtained.
Ex : Reassessment of a client’s functional health patterns
in a home care.
10. METHODS OF ASSESSMENT
The primary methods used to assess client’s are :
1. Observing
2. Interviewing
3. Examining
11. OBSERVING
Observation is a conscious , deleberate skill that
is developed only through and with an organized
approach.
Ex : Client data observed through four senses
that is through vision , smell , hearing and touch.
12. INTERVIEWING
An interview is a planned communication or a
conversation with a purpose.
Ex : History taking
There are two approaches for interviewing :
-Directive approach
-Non directive approach
13. EXAMINING
The physical examination is a systematic data
collection method that uses observational skills
to detect health problems.
To conduct the examination, the nurse uses
techniques of inspection, auscultation, palpation
and percussion.
16. HEAD-TO-TOE ASSESSMENT
Physical Assessment using head toe approach
General Test hearing
General health status Cranial nerves
Vital signs and weight Inspect lymph nodes
Nutrional status Inspect neck veins
Mobility and self care Chest
Observe posture Inspect and palpate breast
Assess gait and balance Inspect and auscultate lungs
Evaluate mobility Auscultate heart
Activities of daily living Abdomen
Head face and neck Inspect, auscultate, palpate four quadrants
Evaluate cognition Palpate and percuss liver, stomach, bladder
LOC Bowel elimination
Orientation Urinary elimination
Mood
Language and memory
Sensory function
Test vision
Inspect and examine ears
17. CONT…..
Extremities
Skin, hair and nails Palpate arterial pulses
Inspect scalp, hair & nails Observe capillary refill
Evaluate skin turgor Evaluate edema
Observe skin lesion Assess joint mobility
Assess wounds Measure strength
Genitalia Assess sensory function
Inspect female client Assess circulation,
Inspect male client movement, & sensation
Deep tendon reflexes
Inspect skin and nails
18. BODY SYSTEM APPROACH
Review of Systems
General presentation of symptoms: Fever, chills, malaise, pain, sleep patterns,
fatigability
Diet: Appetite, likes and dislikes, restrictions, written dairy of food intake
Skin, hair, and nails: rash or eruption, itching, color or texture change, excessive
sweating, abnormal nail or hair growth
Musculoskeletal: Joint stiffness, pain, restricted motion, swelling, redness, heat,
deformity
Head and neck:
Eyes: visual acuity, blurring, diplopia, photophobia, pain, recent change in vision
Ears: Hearing loss, pain, discharge, tinnitus, vertigo
Nose: Sense of smell, frequency of colds, obstruction, epistaxis, sinus pain, or
postnasal discharge
Throat and mouth: Hoarseness or change in voice, frequent sore throat, bleeding or
swelling of gums, recent tooth abscesses or extractions, soreness of tongue or mucosa.
19. Endocrine and genital reproductive: Thyroid enlargement or tenderness, heat
or cold intolerance, unexplained weight change, polyuria, polydipsia, changes in
distribution of facial hair; Males: Puberty onset, difficulty with erections,
testicular pain, libido, infertility. Females: Menses {onset, regularity, duration
and amount}, Dysmenorrhea, last menstrual period, frequency of intercourse, age
at menopause, pregnancies {number, miscarriage, abortions} type of delivery,
complications, use of contraceptives; breasts {pain, tenderness, discharge,
lumps}
Chest and lungs: Pain related to respiration, dyspnea, cyanosis, wheezing,
cough, sputum {character, and quantity}, exposure to tuberculosis (TB), last
chest X-ray
Heart and blood vessels: Chest pain or distress, precipitating causes, timing
and duration, relieving factors, dyspnea, orthopnea, edema, hypertension,
exercise tolerance
20. Gastrointestinal: Appetite, digestion, food intolerance,
dysphagia, heartburn, nausea or vomiting, bowel regularity,
change in stool color, or contents, constipation or diarrhea,
flatulence or hemorrhoids
Genitourinary: Dysuria, flank or suprapubic pain, urgency,
frequency, nocturia, hematuria, polyuria, hesitancy, loss in force
of stream, edema, sexually transmitted disease
Neurological: Syncope, seizures, weakness or paralysis,
abnormalities of sensation or coordination, tremors, loss of
memory
Psychiatric: Depression, mood changes, difficulty concentrating
nervousness, tension, suicidal thoughts, irritability.
Pediatrics: along with systemic approach in case of pediatrics,
measure anthropometric measurement and neuromuscular
assessment.
22. ASSESSMENT TECHNIQUES -
CONT.
INSPECTION
• Close and careful visualization of the
person as a whole and of each body
system
• Ensure good lighting Perform at
every encounter with your client
23. ASSESSMENT TECHNIQUES - CONT.
PALPATION
•Temperature, Texture,
Moisture
•Organ size and location
•Rigidity or spasticity
•Crepitation & Vibration
•Position & Size
•Presence of lumps or masses
•Tenderness, or pain
24. ASSESSMENT TECHNIQUES - CONT.
PERCUSSION
Assess underlying
structures for location,
size, density of
underlying tissue.
25. ASSESSMENT TECHNIQUES - CONT.
AUSCULTATION
•Listening to sounds produced by
the body
•Instrument: stethoscope (to skin)
Diaphragm –high pitched sounds
•Heart
•Lungs
•Abdomen
Bell – low pitched
sounds
•Blood vessels
26. ASSESSMENT PROCESS
Assessment
Organize Documenting
Collect data Validate data
data data
27. ASSESSMENT PROCESS
The assessment process involves four closely related
activities :
1. Collecting data : Process of gathering information.
A) Types of data
subjective objective
28. TYPES OF DATA
When performing an assessment the nurse gathers
subjective and objective data.
Subjective data (symptoms or covert data) : are the
verbal statements provided by the Patient. Statements
about nausea and descriptions of pain and fatigue are
examples of subjective data.
29. Objective data (signs or overt data): are
detectable by an observer or can be measured or
tested against an accepted standard. They can be
seen, heard, felt, or smelt, and they are obtained by
observation or physical examination. For example:
discoloration of the skin.
30. SOURCES OF DATA
Data can be obtained from primary or secondary sources.
The primary source of data is the patient. In most
instances the patient is considered to be the most accurate
reporter. The alert and oriented patient can provide
information about past illness and surgeries and present
signs, symptoms, and lifestyle.
When the patient is unable to supply information
because of deterioration of mental status, age, or
seriousness of illness, secondary sources are used.
31. The Secondary sources of data include family
members, significant others, medical records,
diagnostic procedures,
Members of the patient's support system may be
able to furnish information about the patient's past
health status, current illness, allergies, and current
medications.
Other health team professionals are also
helpful secondary sources (Physicians, other
nurses.)
32. ORGANIZING DATA
Cluster the data into groups of information that
help you identify patterns of health or illnesses.
The nurse uses a written or computerized format
that organizes the assessment data systematically.
The format may be modified according to the
client's physical status.
33. VALIDATING DATA
The information gathered during the assessment
phase must be complete, factual, and accurate
because the nursing diagnosis and interventions
are based on this information.
Validation is the act of "double-
checking" or verifying data to confirm that it is
accurate and factual.
34. DOCUMENTING DATA
To complete the assessment phase, the nurse records
client's data.
Accurate documentation is essential and
should include all data collected about the client's health
status.Data are recorded in a factual manner and not
interpreted by the nurse.
E.g.: the nurse record the client's breakfast
intake as" coffee 240 mL. Juice 120 mL, 1 egg". Rather
than as "appetite good".