Physical Assessment
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Transcript of Physical Assessment
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Physical Assessment
J. Carley RN, MSN, MA, CNEFall, 2009
An Overview
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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
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We’re Late !Let’s Start Report….
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Rm. 3A: Velma Aguon76 y.o. P.I.-Am. FemaleDX: Hypertensive Crisis
Rm. 4A:Mike Smithe32 y.o. Afr-Am Male DX: R/O M.I., HTN
Rm. 5A:Julian Reilly 44 y.o. Cauc. MaleDX: Pericarditis
Rm. 6A:Ashley Wilkes26 y.o. Cauc.FemaleDX: Mitral Stenosis
Rm. 7A:Emsley Owens72 y.o. Afr-AmMaleDX: CHF
Rm. 8A:Redd Butler56 y.o Cauc.DX: Cardiomyopathy,CHF
Rm. 9A:Faith Hopee78 y.o. N.A.FemaleDX: A- Fib
Rm. 10A:Frank Arbugast18 y.o. Afr-AmMaleDX: Sickle-Cell Cr.
Rm. 11A:Aubrey Embry38 y.o. J.A.FemaleDX: Endocarditis
Rm. 12A:Yolanda Zahara55 y.o. M.E. A.FemaleDX: Buerger’s Disease
Today’s Census = 10 [Staffing: 1 RN (You!) , 1 LVN (O), 1 CNA]
“New Admission”RN’s Comment: “Oh, *&%
$#!!!”
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You’ll see the patients on the previous page in Adult Health II……………………………..
But First, Let’s Introduce SomeBackground, or
………CONTEXT !
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Nursing ProcessAssessme
nt
DiagnosisOutcome
Identification
Planning
Intervention
mnemonic“A-D-O-P-I-
E”
List of NANDA Nursing Diagnoses
Content and Processof This Course !
Evaluation
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Nursing Process• A Closer Look
http://usnnursing.pbworks.com/Physical-Assessment-Page
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AssessmentCollect Data: √ Review the Clinical Record √ Interview √ Health History √ Physical Examination √ Functional Assessment √ Consultation * Review of the Literature (--Evidence Based Practice)
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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
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Outcome Identification
--Identify expected outcomes
--INDIVIDUALIZE to the person
--Realistic and MEASURABLE
--Include a TIME FRAME
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Planning
--Establish priorities --Develop Outcomes --Set time frames for outcomes --Identify Interventions --Document Plan of Care
“The Nursing Care Plan”
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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
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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
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Nursing Process
Assessment
DiagnosisOutcome
Identification
Planning
Intervention mnemonic
“A-D-O-P-I-E”Evaluatio
n
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The Interview
&Types of DataSubjective Data
Objective Data
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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”
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The Interview
“Yes.”
“Uh Huh.”
“I see…”
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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…
Subjective Data
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U2: Your Blue Roomhttp://www.youtube.com/watch?v=xS4hJabqRc4
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Learning Games
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Part 2:Interviewing & Documentation
The Nursing Interview
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“The Nursing Process…”
• Mnemonic: “ADOPIE” = “The Nursing Process”
Assessment
Diagnosis
PlanningImplementation
Evaluation
OutcomeIdentification
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Establish Rapport• Get organized• Do not rely on memory• Plan enough time• Ensure privacy• Get focused• Be calm, confident, warm, and
helpful
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Begin the Interview
• Give your name and position
• Verify the client’s name
• Briefly explain your purpose
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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
•
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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
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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
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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
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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
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Part Two: Complete Health History
• Biographical Data• Reasons for Seeking Health Care• History of Present Health Concern• Past Health History• Family Health History
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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
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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
NANDA Nursing Diagnosis List
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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
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Decision Making, Readiness for EnhancedDenial, IneffectiveDentition, ImpairedDevelopment: Delayed, Risk forDiarrheaDisuse Syndrome, Risk forDiversional Activity, DeficientEnergy Field, DisturbedEnvironmental Interpretation Syndrome, ImpairedFailure 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
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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 CompromisedHyperthermiaHypothermiaImmunization Status, Readiness for Enhanced
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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
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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
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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, IneffectiveRape-Trauma SyndromeRape-Trauma Syndrome: Compound ReactionRape-Trauma Syndrome: Silent Reaction
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Religiosity, ImpairedReligiosity, Readiness for EnhancedReligiosity, Risk for ImpairedRelocation Stress SyndromeRelocation Stress Syndrome, Risk forRole Conflict, ParentalRole Performance, IneffectiveSedentary 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
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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
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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, ImpairedTissue Perfusion, Ineffective (Specify: Cerebral,Cardiopulmonary, Gastrointestinal, Renal)
Tissue Perfusion, Ineffective, PeripheralTransfer Ability, ImpairedTrauma, Risk for
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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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YOUR TOPIC GOES HERE• Your Subtopics Go Here
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TRANSITIONAL PAGE
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