Introduction Flashcards
Nurses relied on their natural senses; the client’s face and body would be observed for “changes in color, tem- perature, muscle strength, use of limbs, body output, and degrees of nutrition, and hydration” (Nightingale, 1992).
LATE 1800s–EARLY 1900s
The American Journal of Public Health documents routine client and home inspection by public health nurses in the 1930s.
1930–1949
Nurses were hired to conduct pre-employment health stories and physical examinations for major companies, such as New York Telephone, from 1953 through 1960
Grad nurse (3 years)
BSN (5 years)
1950–1969
The early ____ prompted nurses to develop an active role in the provision of primary health services and expanded the professional nurse role in conducting health histories and physical and psychological assessments (Holzemer, Barkauskas, & Ohlson, 1980; Lysaught, 1970).
1970–1989
Standard 2
“The registered nurse analyzes the assessment data to determine the diagnoses or issues.”
DOCTORS ORDERS
Subjective data, objective data, assess, plan (SOAP)
NANDA
North American Nursing Diagnosis Assessment
4 types of health assessment
IOFE
1. Initial comprehensive assessment
2. Ongoing or partial assessment
3. Focused or problem-oriented assessment
4. Emergency assessment
Collection of subjective data about patient’s perception o his or health of all body parts or systems
Initial Comprehensive Assessment
Collection of objective data gathered during step-by-step physical examination
Initial comprehensive assessment
Data collection that appears after the
comprehensive database is established
Mini-overview of the patient’s condition as a follow-up on health status
Ongoing / partial assessment
To provide prompt treatment
Evaluation of patient’s ABC / CAB
o Airway
o Breathing
o Circulation
Emergency Assessment
These are the sensations, symptoms,
perceptions, desires, preferences, beliefs,
feelings, ideas, and values of the patient
• Anything that can be elicited and verified
only by the patient
• Biographical information
• History of present health concern
• Past health history
• Family history
• Health and lifestyle practices
Collection of subjective data
4 Steps of health assessment
- Collection of subjective data
- Collection of objective data
- Validation of data
- Documentation of data
The crucial step of assessment
• Done to prevent inaccuracy of data
Validation of data
Forms the database of the entire nursing
process
• Needed to ensure valid conclusion
• Narrative technique
o Write patient’s condition
o Contractions
-What’s attached to the patient
o Standing orders
No erasures
SOAPIE
Documentation of data
Obtained by general observation and
performing the four (4) physical techniques (IPPA)
• Assessment of:
o Physical characteristics
o Body functions
o Vital sign measurements
o Behavior
Collection of Objective data
Technique in Documentation of Data
SOAPIE Technique, subjective, objective, assessment, planning, intervention, evaluation
Establishing rapport and trusting
relationship with the patient to elicit
accurate information
Gather information on patient’s
developmental, psychological,
physiologic, sociocultural, and spiritual
statuses to identify deviations that can
be treated with nursing and
collaborative interventions
Interviewing
4 phases of interview
- Pre introductory phase
- Introductory phase
- Working phase
- Summary / closing phase
The nurse reviews the medical record before
meeting with the client
• Nurse knows the patient’s biographical
information
Pre introductory phase
The meeting phase of the patient and client
• The nurse:
o Introduces self to the patient
o Explains the purpose of interview
o Discusses the questions
o Explains reason for taking notes
o Assures patient’s confidentiality
Introductory phase
The nurse:
o Elicits patient’s comments about
biographic data
o Reasons for seeking care
- History of present health concern
- Past health history
- Family history
- Review of body systems for current health problems
- Lifestyle and health practices
- Developmental level of patient
Working phase
COLDSPA
Character, onset, location, duration, severity, pattern, associated factors
Identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others. The client’s birth date, Social Security number, medical record number, or similar identifying data
Biographic Data
- A process of data collection used to verify if the information is legitimate or correct
- One way to pre-empt medications (to prepare beforehand medical interventions)
Data triangulation
To become proficient, the nurse must have basic knowledge in these three areas:
- Types and operation of equipment
needed for the particular examination
- Preparation of the setting, oneself,
and the client for the physical assessment
- Performance of the four (4)
assessment techniques (IPPA)
▪ Inspection
▪ Palpation
▪ Percussion
▪ Auscultation
Physical Examination
Physical assessment techniques
IPPA
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
4 types of palpation
Light palpation, moderate palpation, deep palpation, bimanual palpation
Different assessment of percussion
Eliciting pain
Determining location, size, and shape
Determining density
Detecting abnormal masses
Eliciting reflexes
aims to achieve relevant nursing education, humane working conditions, better career prospects, and a dignified existence for the Filipino nurses.
RA 7164 – 1991
seeks to better protect and improve the nursing profession, but still upholding the same revered state policies and aspirations.
RA 9173 – 2002
Paralysis on one side of the body
Hemipaglia
Indicates progression or worsening of
situation
Weakness (continuous)
Symptoms can include yellowish
pigment
Hepatitis / cirrhosis
Unable to pass stool
o Results to severe constipation
o Black stool
- Upper GI tract involvement
-May include feeling nausea
o Note that the character of the stool is
important
Fecal impaction
The one that must be prioritized according to
Maslow’s hierarchy of needs and ABCs of life
Was used by the physician Alexander The
Great
Triage
Mental and bodily processes
Psychophysiologic
From head to foot assessment
Including hair strands
Cephalocaudal technique
Actual
o Now / on the spot
Anticipated
o Risk / potential
Familial tendencies / Hereditary predisposition
Functional nurse
CMB, charge nurse, medication nurse, bedside nurse
Case management
CCU cardiac care unit and GI (colonoscopy nurse)
The movement of healthcare from the
acute care setting to the community
- Advanced practice nurses have been increasingly used in the hospital as clinical nurse specialists and
in the community as nurse practitioners
1990-present
Nursing process ADPIRE
Assessment, nursing diagnosis, planning, implementation, rationale, evaluation
