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The *nursing process* includes which six phases? (1) *assessment*, (2) *diagnosis(nursing)*, (3) *outcome identification*, (4) *planning*, (5) *implementation*, and (6) *evaluation*. It is a dynamic, interactive process in which practitioners move back and forth within the steps. AD"O"PIE

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The *nursing process* includes which six phases?

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1. Health History-interview-subjective data 2. Physical Exam-the assessment-objective data 3. Documentation of data

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3 aspects of the health assessment

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*Assessment* is the collection of subjective and objective data about a patient's health. *Assessment* Deliberate and systematic collection of data to determine a patient's current and past health status and functional status to determine client's present and past coping patterns.

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Assessment

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*Subjective data* consist of information provided by the affected individual. What patients tells you about their SIGNS AND SYMPTOMS. (Ex. "my head hurts")

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Subjective Data

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*Data* includes signs and symptoms.

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Data

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What a client feels or communicates; subjective data

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Symptom

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Clinical findings-objective data. Clinical manifestations; signs and/or symptoms experienced by client.

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Sign

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*Objective data* include information obtained by the health care provider through physical assessment, the patient's record, and laboratory studies. What a nurse observes. For example, Patient is clenching head as if in pain.

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Objective Data

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1. To gather a health history, gather objective data. 2. Develop nursing diagnosis and care plan. 3. Manage client problems. 4. Evaluate nursing care.

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What is the purpose of a physical examination?

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1. The primary source; patient 2. A secondary source; data can come from a family member, care giver, medical records. Patient is in a coma, is a child or is a patient who can not speak for them self due to their current state. *All data should be verified.*

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Where is Data taken from?

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a. Culture influences the client's behavior. b. Consider health beliefs, use of alternative therapies, nutritional habits, relationship with family, and personal comfort zone. c. Avoid stereotyping. d. Avoid gender bias.

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*Cultural Sensitivity*

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a. Allows clients to explain the meaning of their illness. b. Respects concepts of time, space, contact. c. Respects physical/social activities. d. Respect systems of social organization; provides environmental control.

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What does a culturally-competent nurse do?

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a. Vital signs b. Bathing c. Range of motion d. Activity activities of daily living

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During a routine nursing care exam what information will you be able to gather?

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Client satisfaction and improved clinical outcomes.

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What does recognition and respect of client diversity lead to?

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*Cultural competence* the ability to communicate among/ between cultures and to demonstrate skill in interacting with and understanding people of other cultures.

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*Cultural competence*

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1. Comprehensive- New patients 2. Focused/ Prob. Based- Would likely be used in ER situation. 3. Episodic- Continuing; Follow up. 4. Screening- Preventative

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Types of Assessments (Pg. 3 Box 1-3)

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1. Introduction- Name &title/position (Ex. Jane Doe, RN) 2. Professional dress to include name tag/badge 3. Use Patient's full name (Ex. Mrs. Mary Smith) *no pet names (baby, honey, etc.) 4. Privacy (Close curtain, get patient permission, speak softly, ask ppl. to leave room) 5. Confidential 6. Listen

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Health History Tips

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1. Orientation- Introduction (Who you(nurse) are) 2. Working- Discussion (Ask health status Q's) 3. Termination- Summary- Closing

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The Interview Phase (**Dr. Hale-Brown said make sure to know this)

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Needs an answer other than Y/N. (ask Q in way that patient has to give info.)

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Types of interview Question's (Open ended Questions)

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Questions where all you need is a Y/N answer. No more than one or two words.

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Types of interview Q's (Close ended Q)

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Showing that you are paying attention (Ex. nod head, "uh-huh", "then")

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Types of interview Q's (Back Channeling/ Facilitation)

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Ask about specific issues (Ex. Why are you here?)

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Types of interview Q's (Problem seeking interview)

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Actively listening Facilitation/ Back channeling Paraphrasing Focusing Summarizing Clarification

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Effective Communication Techniques (**Know this)

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Technical terms (Med terms that are not easy for patient to understand) Value judgment statements Talking too much Interruption Authoritarian "Why" Q's (Puts patient on the spot/ makes them defensive)

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Communication Techniques to Avoid

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P- Precipitating or Palliative factors Q- Quality or Quantity R- Region, radiation, related S- Severity T- Timing

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Symptom Analysis (Asking Q's) (**Know this) -Pg.15 Box 2-3

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-Identify patterns of health and illness -identify risk factors physical and behavior problems - obtain knowledge about the patient - Identify patient needs in relation to their environment *Information stays confidential*

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Information obtained from a Health History can...

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describes the client as a whole

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Health history also..

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-Observe Body Language -Eye contact -eye level -patient in street clothes first then change into gown for physical assessment

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During the Interview part of health history..

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*Orientation- Working *Working-Discussion *Termination-Summary-Closing

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3 Phases of Interview Process:

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Client centered.

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Discussion phase is_______

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-Biographical Data/Identifying Data -Chief Complaint -Client Expectations -Present Illness or Health Concerns -Health History(past and present) -Family History _Environmental History -Personal and Psychological History -Spiritual Health -Review of Body Systems -Physical Exam

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Elements of Health History Include:

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Name, Age, Occupation, Health Insurance, Martial Status, etc

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Biographical Data

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Reasons for seeking care

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Chief Complaint

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if sick expands on that.

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Present Illness

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What they expect

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Client Expectations

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Past and Present, Medications, Surgeries, Diagnosis's such as Diabetes, Thyroiditis, etc

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Health History

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includes genogram, paternal and maternal genes

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Family history

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Pollution, Is environment safe

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Environmental History

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How much stress they under, Work, Drugs, sex, etc

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Person and Psychological History

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Has to know clients religion

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Spiritual Health

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This where you get your objective data.

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Physical Exam

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This where you get subjective data from patient.

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Review of Body Systems

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May ask Moms age, have moms information, eating sleeping and play pattern,

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Variation in Health History at Developmental Stages(Newborns)

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school information, growth and developmental,height weight

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Variation in Health History at Developmental Stages(Children)

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healthy lifestyle, drugs, sex and drinking, be sensitive to parents being in interview,risky behavior

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Variation in Health History at Developmental Stages (Adolescence's)

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want to know living arrangements for older adults

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Variation in Health History at Developmental Stages(Older Adult)

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Fetus, gravity of heredity, numbers times pregnant, lifestyle patterns, Comprehensive at first prenatal visit.

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Variation in Health History at Developmental Stages (Pregnant Women)

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Standardized Forms, Electronic, and Narrative

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Documentation and Recording

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Involves Direct Patient Quotes, Normal Health Findings, Alterations in health findings,accurate and objective, Patients Blood Pressure, Height, Weight, Identification of abnormal findings,

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What is some things you will document and record on a patient?

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*complete accurate and descriptive data *Must be recorded concisely, accurately,legibly, without bias or opinion

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Data documented for health care needs to be:

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*improve effectiveness of health care team *prevent repetition *be part of legal document and permanent record *Provide baseline for evaluations of changes and care.

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Importance of Documentation to be accurate and descriptive is to:

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General Appearance/ Behavior *Age *Gender and race *Signs of distress *Gait/Posture *speech *body type

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Components of General Survey

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*Body Movement *Hygiene and grooming *Dress *Body Odor *Client Abuse *Affect and Mood *Mental status and Level of Consciousness (LOC)

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Components for General Survey(continued)

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Vital signs height/weight/body mass index

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First Part of physical Assessment:

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Inspection Palpation Percussion Auscultation Olfaction

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Assessment Techniques

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Have Good lighting Position and expose body parts so that all surfaces can be easily seen Inspect each area for size,shape color symmetry, position and abnormalities

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Inspection

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Using the sense of touch to assess: Surface characteristics Masses Organ Size Pulsations Muscle Rigidity Chest Excursion Tenderness/Pain

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Inspection

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C-Cutdown A-Annoyed G-Guilty E-Eye Opener

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CAGE

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-Used when assessing patients for abuse of alcohol or drugs.

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CAGE

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Look at Infection control, environment, equipment, preparation of client(physical and psychological), encourage patient to ask questions.

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When getting ready for physical assessment:

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Measures orientation and cognitive function. Highest score is 30. Not done on every patient

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Mini Mental Status Exam

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Use hands to touch body parts Use different parts of hands to distinguish texture, temperature and movement Hands should be warm, fingernail short Start with light palpations and end with deep palpations

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Palpation

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Tympany: Gastric air bubble Resonance: Normal Lung Hyper resonance: hyper inflated lung Dullness: liver, full bladder, pregnant uterus Flatness:Muscle

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Percussion

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1/2 inch, irregularity and tenderness

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Light Palpation

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2 in deep, conditions of underlying organs, use one or two hands

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deep palpation

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Palpated with pads of fingers

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Radial Pulse

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Palpated with back of hand(dorsal)

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Temperature

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Palm detects vibrations

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Palm of hand

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skin and index finger detects skin turgery(electricity of skin)

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Skin Turgery

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Tap body with fingertips to produce a vibration. Determines location, size, and density of structures

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Percussion

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Immediate or Blunt Percussion; Percussing hand directly strikes the body wall (done w/ sinuses)

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Direct Percussion

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Mediate Percussion; Involves 2 hands

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Indirect Percussion

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the process of listening to sounds produced by the human body

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Auscultation

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Cardiovascular, Respiratory, Gastrointestional

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Stethoscope used in Auscultation for:

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used to identify the nature and source of body odors

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Olfaction

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Weight(kg) Weight(lb) X 705 --------- ------------- Height(m2) Height(in2)

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BMI=

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Ask Patient to name year, season, date, day. Given points based on answers

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Mini Health Status

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-General Survey -Integumentary System -Head, Face, Neck -HEENT -Respiratory -Cardiovascular -Breasts -Abd -Genitourinary

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Health Assessment Ch.1-5 (Nursing 103) – Flashcards

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