Ch. 6 Flashcards
Observation
Gather significant information about a patient’s emotional condition and health status by observing the patients affect, clothing, personal hygiene and obvious physical conditions (limp or open wound)
Use senses of sight, hearing and smell; helps to guide further aspects of the assessment
Patient interview
Formal, structured discussion where the nurse questions the patient to obtain demographic info, data about current health concerns and medical and surgical histories
Includes developmental, cultural, ethnic and spiritual factors
Orientation phase
Should establish the preferred patient name.
Nurse provides a personal introduction and states the purpose - establishes trust and affects future interactions.
Environment and timing are crucial
Life span (orientation)
Consider the patients generational cohort, which influences behavior and willingness to share personal information
Culture, ethnicity and religion (orientation)
Affect willingness of patient interaction.
Nurses explain need for info that may be considered intimate.
Privacy must be provided.
Traditional treatments should be explored.
Obtain interpretation if language barrier exists.
Gender (orientation)
Personal space, communication patterns and gender considerations should be incorporated.
Requests for same gender nurses should be honored.
Morphology (orientation)
Physical assessment requires patient cooperation.
Positioning may be difficult for some people (obese patients)
Adjusting locations for assessments/examinations may be necessary.
Disability (orientation)
Paralyzed patients.
If mentally disabled patients, ask care provider.
Make any required adaptations during assessment
Working phase
Nurse must stay focused on the purpose.
Needs to individualize the process on the basis of health of the patient and concerns that emerge during the course of the interview.
Active, engaged listening.
How the patient shares info, is more important than what patient says.
Health history (working)
Includes all pertinent info that can guide the development of patient-centered care
Review of systems (working)
Asking patients questions pertaining to each body system.
Termination phase
End of the interview process.
Summarizing and validating the info covered with the patient.
Allow opportunity for patient to interject any other pertinent info not covered.
Describe the next steps.
Inspection
Use vision, hearing and smell to assess physical characteristics of a whole person and individual body systems.
Palpitation
Uses touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness
Percussion
Tapping the patients skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures
Auscultation
Listening with the assistance of a stethoscope to sounds made by organs or systems (heart, blood vessels, lungs and abdominal)
Cannot be delegated
Initial and ongoing assessments.
Initial patient assessments of unstable patients.
Can be delegated
Routine assessment of vital signs of a stable patient.
- first nurses must: determine stability and complexity, verify capability of UAP, collaborate to confirm completion
Comprehensive assessment
Thorough interview, health history, review of systems and extensive physical head-to-toe assessment (evaluation of cranial nerves and sensory organs).
Focused assessment
Brief individualized physical exam conducted at the beginning of an acute care setting work shift to establish current patient status OR during ongoing patient encounters in response fo a specific patient concern
Emergency assessment
Done when time is a factor, treatment must begin immediately, or priorities for care need to be established in a few seconds or minutes.
Based on quick survey of accident or illness onset, followed by narrowly focused physical exam or critical injuries or symptoms and signs
Level 1
Critical: life-threatening condition
Level 2
Emergent: imminently life-threatening condition
Level 3
Urgent: potentially life-threatening condition
Level 4
Nonurgent: stable health condition
Level 5
Fast track: less urgent
Primary data
Direct from patients
Secondary data
Comes from family, friends or other members of the health care team
Subjective data
Spoken info or symptoms that cant be authenticated
Objective data
Signs.
Can be measured or observed.
Observation, physical exams, or lab tests
Cue
Hint or indication of a potential disease process or disorder
Data interpretation
Careful observation and attention to detail.
Avoid inferences - based on personal preferences, past experiences, generalizations or outdated and inaccurate health care info
Accurate interpretation
Requires that the nurse has a wide breadth of knowledge, including disease processes, vital sign parameters, and normal values and outcomes for lab tests.
Body system model
Organizes data on the basis of each system of the body:
Integumentary, respiratory, cardiovascular, nervous, reproductive, musculoskeletal, gastrointestinal, genitourinary, and immune.
Head-to-toe model
Ensures that all areas of concern are addressed
Gordon’s functional health patterns
Assessment data is based on areas of function.
Focuses on patients strengths.
Ex. Health and exercise, nutrition and metabolism, cognition and perception.
Identify methods used during the assessment phase
observation; patient interview; a health history; review of systems; physical exam
Describe techniques used during physical assessment
Inspection, palpitation, percussion, auscultation.
Performed one at a time.
Differentiate among the three types of physical assessments
Complete: admission to hospital, initial visits, or annual physical.
Focused: beginning of each shift, or depending on patients condition.
Emergency: triage, quick, and determine care priorities
Which action by a patient marks the beginning of the physical assessment process?
Greeting the nurse in the exam room
Which factors should be taken into consideration by the nurse before and during a patient interview?
Distance between nurse and patient, traditional treatments used by patient, gender preference, physical condition
Which action by the nurse is most appropriate during the orientation phase of the patient interview?
Ask which name a patient prefers to be called during care to build trust and to show respect
Which activity by the nurse best demonstrates part of the working phase of a patient interview?
Including selected family members in care planning
Which entry in a patients EMR best indicates the need for a nurse to gather secondary rather than primary subjective date?
When a patient is comatose
Which link of questioning by the nurse best represents an appropriate approach to the review of systems aspect of the assessment process?
Do you have any chest tightness, shortness of breath, or difficulty breathing while exercising?
Which cue by a patient can be validated by a lab and diagnostic test result?
Deeply sighing with fatigue
A patient discusses his job stress and family relationships with the nurse during his health history interview. In which organizational framework is this type of data likely to be recorded most extensively?
Functional health patterns model
When initiating a physical exam, which action should the nurse take first?
Assess the patients vitals
If the nurse discovers that a patients right elbow is swollen and painful during an exam, which action should the nurse take first?
Inspect the patients left elbow to compare its appearance
