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Physical Assessment. An Overview. J. Carley RN, MSN, MA, CNE Fall, 2009. Plan of the Day 9/1/2009. √ Introduction to Block 2 √ Introduction to Health Assessment (~0800-0900) √ Interviewing / Documentation (~0900-1000) √ Review of Systems (~1000-1100) Lunch (1200-1500)

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Physical Assessment

An Overview

J. Carley RN, MSN, MA, CNE

Fall, 2009


Plan of the Day 9/1/2009

√ Introduction to Block 2

√ Introduction to Health Assessment (~0800-0900)

√ Interviewing / Documentation (~0900-1000)

√ Review of Systems (~1000-1100)

Lunch

(1200-1500)

√ Hand washing

√ Review of Systems / Health History Interview with partner (p. 33-40 in Jarvis Student Laboratory Manual)

***Complete & Turn it in! Before You Leave Today


We’re Late !Let’s Start Report….


“New Admission”

Today’s Census = 10

[Staffing: 1 RN (You!) , 1 LVN (O), 1 CNA]

RN’s Comment: “Oh, *&%$#!!!”


But First, Let’s

Introduce Some

Background, or

………CONTEXT !

You’ll see the patients on the previous page in Adult Health II……………………………..


Content and Process

of This Course !

mnemonic

“A-D-O-P-I-E”

Nursing Process

Assessment

Diagnosis

Outcome Identification

Planning

Intervention

Evaluation

List of NANDA Nursing Diagnoses


Nursing Process

  • A Closer Look

http://usnnursing.pbworks.com/Physical-Assessment-Page


Assessment

Collect Data:

√ Review the Clinical Record

√ Interview

√ Health History

√ Physical Examination

√ Functional Assessment

√ Consultation

* Review of the Literature

(--Evidence Based Practice)


Diagnosis

*Interpret Data:

√ Identify clusters / cues

√ Make Inferences

* Validate Inferences

* Compare clusters of cues w/ definition,

defining characteristics

* Identify Related Factors

* Document the nursing diagnosis


Outcome Identification

--Identify expected outcomes

--INDIVIDUALIZE to the person

--Realistic and MEASURABLE

--Include a TIME FRAME


Planning

--Establish priorities

--Develop Outcomes

--Set time frames for outcomes

--Identify Interventions

--Document Plan of Care

“The Nursing Care Plan”


Implementation

--Review planned interventions

--Schedule & coordinate patient’s care

--Collaborate w/ other team members--Supervise implementation by delegation

--Counsel patient & family

--Involve the patient in their care

--Referrals as need for continuity of care

--Document care provided


Evaluation

--Refer to the outcomes you established

--Evaluate individual’s condition: compare actual outcomes to expected outcomes

--Summarize results of the evaluation--If expected outcomes not met, identify reasons

--Modify Plan of Care as necessary

--Document Evaluation of Outcomes, and changes (if any) in Plan of Care


Nursing Process

Assessment

Diagnosis

Outcome Identification

Planning

Intervention

mnemonic

“A-D-O-P-I-E”

Evaluation


The Interview

&

Types of Data

Subjective Data

Objective Data


Objective Data:

  • Blood Pressure = 142 / 98 mm Hg

  • Weight = 158 lbs (= 71.8 kg)

  • Oral Intake = 2400 mL / 24 hours

  • Urinary Output = 250 mL / 24 hours

  • Imbalance Between Oral Intake & Urinary Output (above)

“Stuff You can Actually See and Measure”


The Interview

“Yes.”

“Uh Huh.”

“I see…”


Subjective Data

The Interview

  • During the interview, it is a chance for the patient to tell you how he or she PERCEIVES what is going on—what they THINK (or want you to think) their health state is…


U2: Your Blue Room

http://www.youtube.com/watch?v=xS4hJabqRc4


Learning Games

http://www.quia.com/rr/501084.htmlhttp://www.quia.com/rr/503611.htmlhttp://www.quia.com/cm/362353.htmlhttp://www.quia.com/jg/1698754.htmlhttp://www.quia.com/cm/347615.html?AP_rand=1379420649


Part 2:Interviewing & Documentation

The Nursing Interview


“The Nursing Process…”

  • Mnemonic: “ADOPIE” = “The Nursing Process”

Assessment

Diagnosis

Evaluation

Outcome

Identification

Implementation

Planning


Establish Rapport

  • Get organized

  • Do not rely on memory

  • Plan enough time

  • Ensure privacy

  • Get focused

  • Be calm, confident, warm, and helpful


Begin the Interview

  • Give your name and position

  • Verify the client’s name

  • Briefly explain your purpose


How to listen

  • Be an empathetic listener

  • Use short supplementary phrases

  • Listen for feelings as well as words

  • Let the person know when you see body language that conflicts with what they say

  • Be patient if the patient has a memory block

  • Avoid the impulse to interrupt

  • Allow for pauses


How to ask Questions

  • Ask about the main problem first = chief complaint

  • Focus your questions to gain specific information about the signs and symptoms

  • Don’t lead the witness

  • Restate the other person’s words to clarify

  • Use open-ended questions

  • Avoid closed –ended, yes or no questions


How to terminate the interview

  • If the session has been long, give a warning

  • As the person to summarize their primary concerns

  • Ask if there are other areas to be discussed

  • Offer yourself as a resource

  • Explain routines and provide information about who does what

  • End on a positive note


Charting & Documentation

  • If it isn’t written, then it wasn’t done

  • Chart at the time it occurs – if possible

  • Follow facility guidelines

  • Is the information clear and logical?

  • Is it true?

  • Is it non - judgmental?

  • Record all abnormals and normals


Charting guidelines

  • Be precise

  • Stick to the facts

  • Sign your name after each entry

  • SOAP format – focuses on specific problems

  • AIR, DAR, PIE, DIE formats – focus on nursing interventions and client response

  • Prioritize the client problems


Part Two: Complete Health History

  • Biographical Data

  • Reasons for Seeking Health Care

  • History of Present Health Concern

  • Past Health History

  • Family Health History


Lifestyle and Health Practices Profile

  • Description of Typical Day

  • Nutrition and Weight Management

  • Activity Level and Exercise

  • Sleep and Rest

  • Medication and Substance Use

  • Self-Concept

  • Self-Care Responsibilities


NANDA Nursing Diagnosis List

Activity IntoleranceActivity Intolerance, Risk forAirway Clearance, IneffectiveAnxietyAnxiety, DeathAspiration, Risk forAttachment, Parent/Infant/Child, Risk for ImpairedAutonomic DysreflexiaAutonomic Dysreflexia, Risk for

Blood Glucose, Risk for UnstableBody Image, DisturbedBody Temperature: Imbalanced, Risk forBowel IncontinenceBreastfeeding, EffectiveBreastfeeding, IneffectiveBreastfeeding, InterruptedBreathing Pattern, Ineffective


Cardiac Output, DecreasedCaregiver Role StrainCaregiver Role Strain, Risk forComfort, Readiness for EnhancedCommunication: Impaired, VerbalCommunication, Readiness for EnhancedConfusion, AcuteConfusion, Acute, Risk forConfusion, ChronicConstipationConstipation, PerceivedConstipation, Risk forContaminationContamination, Risk forCoping: Community, IneffectiveCoping: Community, Readiness for EnhancedCoping, DefensiveCoping: Family, CompromisedCoping: Family, DisabledCoping: Family, Readiness for EnhancedCoping (Individual), Readiness for EnhancedCoping, IneffectiveDecisional Conflict


Decision Making, Readiness for EnhancedDenial, IneffectiveDentition, ImpairedDevelopment: Delayed, Risk forDiarrheaDisuse Syndrome, Risk forDiversional Activity, Deficient

Energy Field, DisturbedEnvironmental Interpretation Syndrome, Impaired

Failure to Thrive, AdultFalls, Risk forFamily Processes, Dysfunctional: AlcoholismFamily Processes, InterruptedFamily Processes, Readiness for EnhancedFatigueFearFluid Balance, Readiness for EnhancedFluid Volume, DeficientFluid Volume, Deficient, Risk forFluid Volume, ExcessFluid Volume, Imbalanced, Risk for


Gas Exchange, ImpairedGrievingGrieving, ComplicatedGrieving, Risk for ComplicatedGrowth, Disproportionate, Risk forGrowth and Development, Delayed

Health Behavior, Risk-ProneHealth Maintenance, IneffectiveHealth-Seeking Behaviors (Specify)Home Maintenance, ImpairedHope, Readiness for EnhancedHopelessnessHuman Dignity, Risk for CompromisedHyperthermiaHypothermia

Immunization Status, Readiness for Enhanced


Infant Behavior, Disorganizednfant Behavior: Disorganized, Risk forInfant Behavior: Organized, Readiness for EnhancedInfant Feeding Pattern, IneffectiveInfection, Risk forInjury, Risk forInsomniaIntracranial Adaptive Capacity, Decreased

Knowledge, Deficient (Specify)Knowledge (Specify), Readiness for Enhanced

Latex Allergy ResponseLatex Allergy Response, Risk forLiver Function, Impaired, Risk forLoneliness, Risk for


Memory, ImpairedMobility: Bed, ImpairedMobility: Physical, ImpairedMobility: Wheelchair, Impaired Moral Distress

NauseaNeurovascular Dysfunction: Peripheral, Risk forNoncompliance (Specify)Nutrition, Imbalanced: Less than Body RequirementsNutrition, Imbalanced: More than Body RequirementsNutrition, Imbalanced: More than Body Requirements, Risk forNutrition, Readiness for Enhanced

Oral Mucous Membrane, Impaired


Pain, AcutePain, ChronicParenting, ImpairedParenting, Readiness for EnhancedParenting, Risk for ImpairedPerioperative Positioning Injury, Risk forPersonal Identity, DisturbedPoisoning, Risk forPost-Trauma SyndromePost-Trauma Syndrome, Risk forPower, Readiness for EnhancedPowerlessnessPowerlessness, Risk forProtection, Ineffective

Rape-Trauma SyndromeRape-Trauma Syndrome: Compound ReactionRape-Trauma Syndrome: Silent Reaction


Religiosity, ImpairedReligiosity, Readiness for EnhancedReligiosity, Risk for ImpairedRelocation Stress SyndromeRelocation Stress Syndrome, Risk forRole Conflict, ParentalRole Performance, Ineffective

Sedentary LifestyleSelf-Care, Readiness for EnhancedSelf-Care Deficit: Bathing/HygieneSelf-Care Deficit: Dressing/GroomingSelf-Care Deficit: Feeding Self-Care Deficit: ToiletingSelf-Concept, Readiness for EnhancedSelf-Esteem, Chronic LowSelf-Esteem, Situational LowSelf-Esteem, Risk for Situational LowSelf-MutilationSelf-Mutilation, Risk for


Sensory Perception, Disturbed

(Specify: Auditory,Gustatory, Kinesthetic, Olfactory Tactile,Visual)

Sexual DysfunctionSexuality Pattern, IneffectiveSkin Integrity, ImpairedSkin Integrity, Risk for ImpairedSleep DeprivationSleep, Readiness for EnhancedSocial Interaction, ImpairedSocial IsolationSorrow, ChronicSpiritual DistressSpiritual Distress, Risk forSpiritual Well-Being, Readiness for EnhancedSpontaneous Ventilation, ImpairedStress, OverloadSudden Infant Death Syndrome, Risk forSuffocation, Risk for


Suicide, Risk forSurgical Recovery, DelayedSwallowing, Impaired

Therapeutic Regimen Management: Community,IneffectiveTherapeutic Regimen Management, EffectiveTherapeutic Regimen Management: Family,IneffectiveTherapeutic Regimen Management, IneffectiveTherapeutic Regimen Management, Readiness for EnhancedThermoregulation, IneffectiveThought Processes, DisturbedTissue Integrity, Impaired

Tissue Perfusion, Ineffective (Specify: Cerebral,Cardiopulmonary, Gastrointestinal, Renal)

Tissue Perfusion, Ineffective, PeripheralTransfer Ability, ImpairedTrauma, Risk for


Unilateral NeglectUrinary Elimination, ImpairedUrinary Elimination, Readiness for EnhancedUrinary Incontinence, FunctionalUrinary Incontinence, OverflowUrinary Incontinence, ReflexUrinary Incontinence, StressUrinary Incontinence, TotalUrinary Incontinence, UrgeUrinary Incontinence, Risk for Urge Urinary Retention

Ventilatory Weaning Response, DysfunctionalViolence: Other-Directed, Risk forViolence: Self-Directed, Risk for

Walking, ImpairedWandering


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