Evidence Informed Assesment Flashcards
What is subjective data?
It is how the person perceives what they are saying, it comes from opinions, experiences and perceptions. History is an example of subjective data.
What is objective data?
It is when you use senses to gather data. An example of this would be a physical examination.
What is diagnostic reasoning?
Attending to cues, formulating hypotheses, gathering data and evaluating hypothesis and data.
What is the nursing process?
Start with assessment (come back to this), diagnose, outcome identification, planning, implementation, evaluation… then back to assessment if the outcome was not what was planned
What is the critical thinking model?
Identify assumptions, identify an organized and comprehensive approach, validation, distinguishing normal from abnormal, making inferences, then clustering related cues. Also be able to say if something is not significant, recognize inconsistencies and identify patterns or missing info.
Evidence informed assesment?
Evidence evolves, so got to newest evidence
Work to build trust
Pay attention to social context of patients
Do not be judgy, understand the climate now (maybe they only have access to this care and not a different one)
Interview process?
Ask relevant questions
Help them towards optimal health
Remember to be in an appropriate place with privacy, and think of the time
Factors to consider during patient interviews?
Time and place
Introduction and explanation
Purpose
Length
Expectations
Presence of others
Confidentiality
Costs
Communication process?
Make sure what you sent is received in the way you wanted it to be
Show patience - you have all the time in the world to listen to them
Let the patient know you are documenting
What are some challenges of note taking?
Impedes eye contact
Shifts attention away from patient
Interrupts patient’s narrative flow
Impedes observation of nonverbal behaviour
Can be threatening to patient
How can you make note taking less stressful
Listen, then write down, then validate
Communication techniques? (verbal)
Open and closed ended questions
Silence, reflection, empathy, clarification, confrontation, interpretation, explanation, summary
Silence makes patients want to elaborate more
Communication techniques? (Non-verbal)
Physical appearance
Posture
Gestures
Facial expressions
Eye contact
Voice
Touch
What are 10 traps of interviewing
- providing false assurance
- Giving unwanted advice
- using authority
- Using avoidance language
- Engaging in distancing
- Using professional jargon
- Using leading biased questions
- Talking too much
- Interrupting
- Using “why” questions
Interviewing in challenging situations
Always speak to the patient
Cultural and social considerations?
Communication
Perspectives on professional interactions
Etiquette
Space and distance
Gender and sexual orientation
Overcoming communication barriers?
Interpreters- hospital provided-not family or friends
Speak to patient though
Two types of assesments?
Subjective-health history, not measurable
Objective-physical exam, measurable
Difference between medical and nursing assessment?
Meds-diagnose and treat disease
Nursing-diagnose and treat human responses to actual or potential health problems
Health history step by step?
Biographical data
Reason for seeking care
Current health or history of current illness
Past health
Family history
Allergies
Meds
Review of systems
Biographical data
Name
Address and phone #
Age and birthdate
birthplace
gender
Marital status
Ethnocultural background
occupation
Source of info
Chief concern (reason for seeking care)
A brief statement in patient’s words
Subjective sensation (symptom)
Sign (detectable on physical exam)
Current health
O -Onset (when did symptoms start)
P -Provocation or palliative (does anything make it better)
Q -Quality or quantity ( describe pain, stabbing, stinging)
R -Region or radiation (point to where you feel it)
S -Severity (1-10) (pain level)
T -Timing (when does it hurt)
U - Understanding patients perception (do they have a guess?)
Past health
Childhood illness
Accidents or injuries
Serious or chronic illnesses
Hospitalizations
Operations
Obstetrical history
Immunizations
Most recent exam date
Current meds
Family history and social history
Smoking, vaping, drugs, alcohol
Health of close family members
Cause of death of blood relatives
Family history of conditions or illnesses (obesity, blood pressure, strokes, mental health issues)
Physical examination
Inspect
Palpate
Percussion
Auscultation
(abdomen is different order)
General Survey
Physical appearance
age, sex, consiousness, skin colour, facial features
Body structure
stature, nutrition, symmetry, posture, position, body build
Overall assess their appearance
Measurements
Weight (balance scale heigh to weight ratio)
Height
BMI calculation
Waist to hip ratio
Temperature vital sign
Hypothalamus as thermostat mechanism
What influences temperature
Diurnal cycle
Menstrual cycle
Exercise
Age
Exposure to cold
Surgery
Infection
Neuro disease
Tea/ coffee
(take temp after they sit for a bit)
Routes of temp measurement
Oral (prefered)
Axillary (0.5 lower than oral)
Rectal (unconscious-0.5 higher than oral)
Tympanic membrane (less invasive)
Temporal artery
Vital signs pulse
Stroke volume
Rate
Rhythm
Force
Elasticity
How to take pulse
3 fingers, palpate radial pulse at wrist
Count 30s then x2
Grade the pulse
3+ is full and bounding
2+ is normal
1+ is weak
0 is absent
Influences on pulse
Caffeine
Meds
Anxiety
Age
Breathing
Exercise
Substance use
Respiration vital sign
count for 30s then multiple by 2
Respiration affects
Weight
Age
Illnesses
Anxiety
Substances
Caffeine
Blood pressure - vital sign
The force pushing against vessel wall
systolic is the pressure against the artery during contraction
Diastolic is the pressure of elastic recoil during relaxation
How do you measure blood pressure
Stethoscope and sphygmomanometer
Palpate brachial artery
Inflate until pulse is lost
Reflate 20-30 mm Hg and then deflate listening (with bell) for Korotokoff’s sounds
What affects blood pressure?
Age, gender, ethnocultural background, diurnal rhythm, weight, exercise, emotions, stress
Oxygen Saturation
arterial oxygen saturation
95-99%
Normal vital sign measurements
Breathing-16-20 breaths a minute
Blood pressure- 120/80
Pulse- 60-100
O sat - 95%-99%
Temp- 36.5-37.5 celcius
