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					Introduction to Assessment
         Nur 869


          Lab 1
Assessment
w Systematic   & continuous collection,
  validation, and communication of
  client data
w Nursing process
w Initial and ongoing
w Medical vs Nursing
w Essential components
Purposes of Assessment
w   Obtain Baseline Date regarding functional abilities
w   Supplement, confirm, or refute date obtained in
    nursing history
w   Obtain data that helps establish nursing diagnoses
    and plan care
w   Evaluate physiologic outcomes of health care and
    thus client progress
w   Screen for presence of risk factors
Types of Assessment

w Initial
w Focused
w Emergency
w Ongoing
Types of Data
w Objective   Data      w Subjective   Data
  • “signs”               • “symptoms”
  • info perceived by     • info perceived
    the senses              only by affected
                            person
  • Ex: T 101, moist      • Ex: feeling
    skin                    nervous, tired
Characteristics of Data
w Complete


        &
w Factual
 Accurate

w Relevant
Problems r/t Data Collection
w Organization
w Omission
w Irrelevant or
  Duplicate Data
w Misinterpretation
w Too little data
w Documentation
Why is a health history taken?
w Patterns of
  wellness/illness
w Physical &
  Behavioral risk
  factors
w Deviations from
  norm
w Nurse as a resource
Functional Health Patterns
w   Health Perception/      w   Sensory-Perceptual
    Management              w   Cognitive
w   Nutritional-Metabolic   w   Role-Relationship
w   Elimination             w   Coping-Stress
w   Activity-Exercise           Tolerance
w   Sexuality-              w   Value-Belief
    Reproduction
w   Sleep-Rest
Nursing Health History
w   Chief Complaint             w   Past Medical History
w   Present Problem             w   Family History
    •   Usual health status     w   Personal & Social
    •   Chronological story         History
    •   Impact on functioning   w   Review of Systems or
    •   Medications                 Functional Patterns
Client Profile – UK Clinical Setting
w   Biographical Data     w   Current Treatments
w   Chief Complaint       w   Past Illnesses or Past
w   History of Present        Hospitalizations
    Illness               w   Allergies
w   Current Medications
General Survey – Clinical Setting
w   Age/Sex/Race     w   Speech
w   Mental Status        • Use of language
w   Behavior             • Thought Process
                         • Reliability as historian
w   Mood
                     w   Height/Weight
w   Appearance
                     w   Vital Signs
w   Body Type
w   Posture
w   Body Mechanics
Explanation- Affect/Mood
w   Affect – observable behaviors which
    indicate the feelings or emotional status of
    the client.

w   Mood – term which refers to the client’s
    emotional state as described by the client.
Documentation Terms
w   Affect           w   Mood
    •   Broad            •   Appropriate
    •   Restricted       •   Inappropriate
    •   Blunted          •   Depressed
    •   Flat             •   Anxiety
    •   Labile           •   Agitated
                         •   Elated
                         •   Manic
                         •   Euphoric
                         •   Euthymic (normal)
                         •   irritable
General Principles - History
w Explain  purpose
w Communication techniques
w Utilization of data sources
w Document
w Avoid interruptions or tiring the client
w Consider client’s developmental level
Developmental Principles
w Pediatric            w Geriatric
  • Parent/child         • Do not
    interactions           stereotype
  • Integrate child      • Assess and
  • Respect                accommodate:
    adolescent, give        • sensory &
    choices                   physical
                              functioning
Psychosocial Considerations -
History
w Avoid  stereotypes
w Healthcare beliefs
w Language differences
w Eye contact
w Non-judgmental
w Stressors/Coping Mechanisms
Cultural Awareness Considerations

w Time Orientation
w Activity Orientation
w Human Nature Orientation
w Human-Nature Orientation
w Relational Orientation

          • Seidel, 2003, pp. 43.
History - Biographical Data
w Name             w Birthplace, date
w Race             w Address
w Age              w Source of medical
w Gender             care
w Marital status   w Insurance coverage
Past Health History
w Previous hosp. &
  surgeries
w Allergies
w Illnesses &
  Accidents
w Immunizations
w Medications
w Habits/Lifestyle
w ADLs
Client’s Family History
w   Blood relatives

w   Significant others

w   Health history

w   Family as resource

w   Stressors in family
Present Illness/Health Concerns
w Onset
w Duration
w Location, quality, and intensity
w Precipitating factors
w Relief factors
w Client’s expectations
w Subjective and Objective data
PQRST – Characterize Symptoms
w   Precipitating factors
w   Quality
w   Radiation
w   Severity
w   Temporal Factors
OLD CARTS –
w   Onset
w   Location
w   Duration
w   Character
w   Aggravating factors
w   Relieving factors
w   Temporal factors
w   Severity
Reasons for Seeking Healthcare
w Chief   complaint
w Why?
w Quotes
w Specify
w Clarify
Resources
w Home  and outside environment
w Community resources
w Financial
w Family & significant others
w Consider Basic Human Needs
Medical Diagnostic Data
w Medical   vs
  Nursing
  Diagnosis
w Nursing
  Implications r/t
  Medical
  Diagnosis
Contributions of Lab Data
w Verifies data
w Provides baseline
  information
w Evaluates outcomes
w Identifies problems
  missed in history
  and assessment
Test: Complete Blood Count
(CBC)
w Analysisof peripheral venous blood
  specimen
w Main components:
  • RBC = red blood cell count
    (erythrocytes)
  • WBC = white blood cell count
    (leukocytes)
  • Hgb = hemoglobin
  • Hct = hematocrit
Test: Urinalysis (UA)
w Analysis of a urine
  specimen
w Screens for:
    • urinary infection
    • renal disease
    • diabetes mellitus
Urinalysis
w Main    components
  •   pH-                 4.6 - 8.0
  •   Protein-            up to 10mg/100ml
  •   Specific gravity-   1.003 - 1.030
  •   Glucose-            negative
  •   Ketones-            negative
  •   Blood-              up to 2 RBCs
Test: Electrolytes (lytes, e-)
w Inorganic
  substances in the
  body that conduct
  electrical current
w Usage:
    • Assess fluid
      balance
Electrolytes
w Main   Components:
  •   Na+      sodium
  •   K+       potassium
  •   Cl-      chloride
  •   Ca       calcium
  •   P        phosphate
  •   Mg       magnesium
Test: Chest X-Ray (CXR,
PA Chest, PA & LAT Chest)
w Radiographic exam
  of the thorax
w Visualizes
  respiratory &
  cardiac function
w Identifies & follows
  progression/
  remission of dx
  process
Test: Arterial Blood Gas (ABG)
w   Assesses the adequacy
    of ventilation and
    oxygenation via
    arterial blood
w   Use: measures
    respiratory and
    metabolic (renal)
    disturbances
Arterial Blood Gases
 w Main
  Components:
   •   pH
   •   PaCO2
   •   PaO2
   •   HCO3
   •   SaO2
General Nursing Implications
w Assess  client’s readiness to learn
w Explain procedure to client
w Assist client in dealing with the test
w Provide privacy
w Prepare client for test
w Universal precautions
w Send specimens promptly
Specific Nursing Implications
w Electrolytes:
  • Note diet, food and fluid intake
  • Note s/s that could affect fluid balance
    (N/V/D)
w Chest   X-Ray:
  • Transport
  • Remove metal objects
  • Stand clear
Specific Nursing Implications
w Arterial   Blood
 Gases
  • Anticoagulants?
  • Time drawn
  • Check site for
    bleeding
  • Pressure
  • Sample on ICE
  • STAT to lab
Physical Assessment:
Pediatric Principles
w Assess:
  • coping ability
  • previous knowledge
  • readiness
w Encourage
  questions
w Explain at
  developmental
  level
Physical Assessment:
Pediatric Principles
w Use concrete terms
w Small amounts of
  info at a time
w Simple & clear
  explanations
w Only offer choices
  that are available
w Honest
  praise/rewards
Physical Assessment Methods

  w Inspection
  w Palpation
  w Auscultation
  w Percussion
Equipment
w Stethoscope
w Pen light
w Blood Pressure Cuff
w Thermometer
w Watch with second hand
Inspection

w Assessment
 process during
 which the nurse
 observes the
 client
Inspection
w Initial contact and ongoing
w Use olfaction, touch
w General appearance, body language
w Systematic unhurried approach
w Expose part, respect privacy
w Examine: color, size, shape, position,
  symmetry (compare like areas)
w Know “normals”
w Observe “normals/abnormals”
Palpation

w The use of the hands and the sense
 of touch to gather data
Palpation
w Detects texture, shape, temp, movement,
  pain, moisture
w Short fingernails, warm hands
w Gentle approach
w Light palpation first, if pain - STOP!
w Palpate tender areas last
w Three types:
   • Light palpation (1/2 inch)
   • Deep palpation (1 inch)
   • Bimanual deep palpation (2 hands)
Auscultation
w The  act of
  listening to
  sounds within the
  body to evaluate
  the condition of
  body organs
w (stethoscope)
Auscultation
w Stethoscope:
  • bell for low pitch sounds (cardiac sounds)
  • Diaphragm for high pitch sounds (bowel,
    breath, normal cardiac)
w4    characteristics of sounds
  •   Frequency/pitch: # vibrations per second
  •   Loudness: soft, medium, loud
  •   Quality: types; gurgling, blowing
  •   Duration: short, medium, long (specify)
Auscultation
w Quiet environment
w Know landmarks
w Know “normals”
w PRACTICE! PRACTICE!
  PRACTICE!
w Requires concentration, practice, and
  application of knowledge
Percussion
w Tapping of
 various body
 organs and
 structures to
 produce vibration
 and sound.
Documentation - Purpose
w   Communication          w   Education
w   Quality Assurance      w   Statistics
w   Legal                  w   Accrediting/Licensure
w   Reimbursement          w   Historical Document
w   Research
w   Planning Client Care
Principles of Documentation
w   Timing            w   Completeness
w   Confidentiality   w   Standard Terminology
w   Permanence        w   Brevity
w   Signature         w   Legibility
w   Accuracy          w   Legal Awareness
w   Sequence
w   Appropriateness
Study Guide
w   State the purposes of the physical exam.
w   Name the necessary equipment need to perform
    a physical exam.
w   Describe the four basic techniques used in
    physical examination.
w   Describe guidelines for preparing a client and
    the environment for a physical examination.
w   What are the components of a general survey?

				
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