Intro to Assessment and Communication Flashcards
ISBARR
Introduce Situation Background Assessment Recommendations Repeat
Define health assessment
collect and analyze data to make judgments about wellness (may be used by self and others)
may involve individuals/families/communities
What are the 4 purposes of nursing health assessment?
- understand person’s experience
- identify strengths that promote health (what independence they can have)
- identify needs and clinical problems
- evaluate the effects of therapeutic plans and interventions
5 types of assessments
admission focus time lapse emergency head to toe (basic nursing)
admission assessment
comprehensive, includes other providers, health background
focus assessment
responding to a change or apparent situation (e.g., knowing that they had an intervention on their foot)
time-lapse assessment
looking at the patient over time
emergency assessment
critical – supporting oxygenation and cardiovascular system
could also be a mental health assessment
basic nursing assessment
head to toe model (there are a few options, will be finetuned as we specialize)
four phases of interviewing
preparatory - before meeting
introductory - nurse and pt meet
maintenance - work towards goal
concluding - interview complete
two types of data
subjective (symptoms) and objective (signs)
two sources of data
primary: the patient
secondary: all other sources including diagnostic tests
consider how reliable the source is
inspection
close and careful visualization of the person as a whole and of each body system
- good lighting
- privacy and comfort
- every encounter
- compare findings to subjective data
- inform pt of need to look at area and why
gluteal cleft
butt crack :)
critical observation
compare to patient’s baseline and “normals” for each body part
light palpation
use of hands/touch to gather data: 1cm or 1/2inch depression
deep palpation
use of hands/touch to gather data: 5cm or 2 inches
which part of hand do you use to assess skin temp
back (dorsal)
which part of hand assesses texture, moisture, tenderness?
fingers
when do you palpate known tender areas
last (don’t hurt them first – you’ll get a more accurate exam if they’re in less pain for most of the exam)
percussion
tapping of body organs and structures to produce vibration and sound (direct and indirect)
auscultation
listening to sounds (usually using stethoscope)
four characteristics of sound
pitch - high/low
intensity - soft/loud
quality - gurgling, blowing, musical
duration - short, long, when
should the stethoscope be used on the skin or over clothes
on the skin (preferred, later on you may be able to use over clothes)
