health assessment Flashcards
difference between nursing and medical diagnosis
medical: focus on the illness or injury, remains constant till cure if affected
nursing: focuses on response of actual and potential health problems, changes as patient does
why perform assessments
- To identify actual and potential problems
- To gather information to guide a client’s plan of care
- Understand a patient’s cultural andreligious practices
- Provides a baseline so we can identify changes
- Alerts staff to deviations from normal values
- Allows a client to verbalise their symptoms, story, concerns, expectations
- Early indicator of need to involve allied health personnel in client’s care
- Provides legal protection for nurses through documentation of assessment findings
role of EN in assessment
- Accurately collects and reports data and information on the patient’s health status
- Uses health care technology appropriately
- Uses a range of data gathering techniques changes in health to the RN or appropriate member of the health team
- Recognises normal and abnormal states of the individual
- Develops a rapport with patient and family to optimise information sharing
anmc guidelines (Australian Nursing and Midwifery Council)
To demonstrate critical and reflective thinking skills including the reporting of changes in health and functional status and individual responses to health care interventions.”
subjective and objective data
sub: not measurable - past history, pain
ob: measurable - temp, height
neurological
brain, spine, nervous system
cardiovascular
heart, blood vessels
respiratory
lungs, urt, lrt
digestive
stomach, intestines, rectum
endocrine
pancreas, thyroid, gonads and other hormone producing glands
renal
kidney, bladder
reproductive
sexual organs
musculo-skeletal
muscles, bones
integumentary
skin
assessment techniques
- inspection (looking, physical appearance)
- palpation (touch)
- auscultation (listening with stethoscope, backwards ‘S” )
- percussion (tapping surface to determine the underlying structure)
