Holistic Health Assessment Flashcards
What is the purpose of a physical assessment:
- Obtaining baseline data
- Comparing and considering findings aganst data from hisotry
- Suporting relevant nursing diagnoses & plans of care
- Providing immunizations
- Monitoring change/progress, deterioration/improvement, effectiveness of treatments/interventions
- Making clinical judgements about health status & client needs
What is Subjective Data?
Gathered from the client
- When clients share their reason for seeking care, their symptoms, their experiences, how they lives have been impacted
- Can not be verified by the nurse
- Can come from other sources: family members, clients chart
How to organize Subjective Data?
O - onset
- When did the problem start?
- Were you doing anything at the
time it started?
L - location
- Where is it?
D - duration
- How often has this been occurring?
- How long does it last?
C - characteristics
- Can you describe how it feels?
A - aggravating factors
- Does anything make it worse?
R - relieving factors
- Does anything make it better?
T - timing
- Does it bother you at particular
times of the day?
- How long did it last?
S - severity
- On a scale of 0 - 10, can you rate
your pain?
- What is it at it’s best?
- What is it at it’s worst?
S - self-perception
- What do u think may be causing it?
- What are you concerned about?
What is SAMPLE framework?
- subjective data includes associated symptoms, medical history, regular medications, and allergies
S - signs and symptoms
A - allergies
M - medications
P - past history
L - last meal
E - events leading up to this
What is Objective Data?
- what the nurse collects through noticing with senses
- facts - they can be sensed, measured, validated, and proven
- ex. findings from physical assessments
What are the components of the General Survey?
A - appearance and behaviour
S - speech
E - emotion/affect
P - perception
T - thought process
I - intuition
C - cognition
What are the components of Tanners Clinical Judgement Model?
- Using the information you have to make a good decision
1) Noticing (visual)- picking up the information using your senses
2) Interpreting - making sense of your data
- Assign meaning, life experience, social norms
3) Responding- taking appropriate action
- Life experiences, personal ethics, sociocultural norms
4) Reflecting - analyzing the situation during and after
- Positive outcome, actions match values, what is the right thing to do
- 2 types
1. In action - is my approach
working?
2. On action - would I do things
differently next time?
What is the Nursing Process?
- a framework that allows nurses to systematically address a clients health problem in a client-focused way
The phases are :
- distinct from each other
- LINEAR
- interrelated
- dynamic
- overlap
What are the Phases of the Nursing Process?
- Assessment
- Analysis
- Planning
- Implementation
- Evaluation
Assessment
- Subjective data collected from client
- Objective data collected by nurse (using sense)
- Establish priorities for assessment
Analysis
- Identify abnormal data and strengths
- Cluster data, look for patterns, consistencies/inconsistencies
- Draw inferences, consider different angles
- Consider nursing diagnoses (what’s wrong from a nursing perspective)
- Look for defining characteristics
- Confirm/rule out nursing diagnoses
- Document conclusions
Planning
- Goal-setting with client (SMART goals)
- Discover what matters to the client
- Include collaborative outcomes + goals
- Outcomes= specific, detailed, often, linked directly to an action or intervention
- Includes short and long-term planning
- Includes client education
Implementation
- Aka interventions
- Nursing actions based on knowledge, skill, ability, and judgement
- Prevent, resolve, control/manage health conditions
- Includes health promo and optimization of function
- Influenced by workplace/agency, resources
- Includes therapeutic communication, education, monitoring, psychomotor, skill
Evaluation
- Make judgements about client progress/responses to interventions
- Analyze effectiveness of nursing carer
- Review opportunities to access interprofessional team and resources
- Consider goals, met vs unmet, factors interfering/facilitating goal achievement
- Monitoring, prepare to make changes according to outcomes/responses
4 Physical Assessment Techniques
- The order of the techniques used for the physical assessment is always the same
- Except for gastrointestinal assessments where auscultation comes before palpitation
1) Inspection
2) Palpitation
3) Percussion
4) Auscultation
