introduction to physical assessment Flashcards
assessment is….
A collection of data about an individuals health care
Subjective Data
What the patient TELLS YOU. what you observe
Objective Data
What is ON the patient
Data Base
The chart and everything else we have going on.
An organized assessment is the starting point of every approach to….
Clinical reasoning…learning and experience
bedside, vital signs, an idea of what is going on.
WHY do we do assessments?
- make clinical judgement or diagnosis
- assess a person’s RISK or actual health problems and life processes
- Diagnose higher levels of wellness
- starting point of all models of clinical reasoning
Baseline
first set of data we collect about a patient
we then know if something has changed
First level priority
Emergent, life threatening, and immediate
ex. CODING airway problems, circulation problems
Second Level priority
Next in urgency, requiring attention so as to avoid further deterioration.
ex. mental status changes, acute urinary elimination problems, diabetic who hasn’t had insulin, abnormal lab values, risk of infections,
Third level priority
Important to the patients health but can be addressed after more urgent problems are addressed
ex. lack of knowledge, activity, rest
The assessment process
Nurse
Professional attitude
Established rapport..no trust= no information
Reflection
Repeat what you have heard to encourage more details
Empathy
Show understanding
Facilitation
Encourage patients to say more
Sympathetic approach
Do something in the same order
spend more time listening than talking
use silence to encourage the patient to continue talking
Effective communication: Seeking connection
At the start open- ended questions: this gives the patient free range to tell us what is wrong.
“ What brings you to the office?”
“ Have there been any changes since the last office visit:
Direct Questions
This is after open ended questions. we need to be more specific
“ How long have you had symptoms?”
Where does it hurt?
Leading questions
MOST RISKY
“ That is a horrible tasting medicine isn’t it?”
Verbal Responses: Empathy
Recognizes a feeling and puts it into words
Verbal Responses: Clarfication
Use when person’s words are ambiguous or confusing
ex. “ when you said…what did you mean?”
Verbal Responses: Confrontation
May focus on discrepancy or inconsistency in person’s narrative
ex. someone who says they are depressed but they do not act or look depressed ( SMILING)
Verbal Responses: Interpretation
It links events, makes associations, implies cause, ascribes feelings
Verbal Responses: Explanation
These statements inform the patient
Verbal Responses: Summary
Final review of what person has said, it condenses facts and presents your view of health problems
ten traps of interviewing
- providing false assurance or reassurance
ex. everything will be ok - giving unwanted advice
ex. pregnant etc. - using authority
ex. do this because I said so - using avoidance language
- engaging in distancing
- using professional jargon
ex. teach the patient the language - using leading or biased questions
- talking too much
- interrupting
- using “ WHY” questions
Types of ASSESSMENTS: complete
Includes complete health history and full physical examination
Types of ASSESSMENTS: focused or problem centered
only one thing wrong
for limited or short term problems
types of ASSESSMENTS: follow up
Evaluate problems at regular intervals
ex. high blood pressure give medicine- come back in 2 weeks..
Types of ASSESSMENTS: emergency
Rapid collection of data with concurrently lifesaving measures
ex. coding or heart attack
Cultural Competence: Culturally sensitive
Possessing basic knowledge of and constructive attitudes toward diverse cultural populations
Culturally appropriate care
ex. johavah’s witness
applying underlying background knowledge necessary to provide the best possible health care
Culturally competent
Understanding and attending to total context of patients situation including the following: 1. immigration status 2. stress and social factors 3. cultural similarities and differences " all that is going on"
SYMPTOMS
Subjective information
ex. spoken information
SIGN
Objective information
physical examination or in lab reports
“ find out -objective
Source of Information
State who is giving the history
- usually there is a person although source may be relative or friend
“ Who gives the information
Is the source RELIABLE?
A reliable person ALWAYS gives the same answers when questions are rephrased later in the interview
Parts of Health History: Biographical data
- name
- address
- phone number
- age
- birth date
- race
- ethnic origin
- occupation
- marital status
- gender
this is first
Chief Complaint ( CC)
A brief statement in the person’s own words that describe the reason for the visits
ex. “ I have a sore throat
NOT INTERPRETATION of what they said-it IS what they said
History of present Illness
Use OLDCARTS Onset ( when did this start?) Location/radiation ( upper arm) Duration ( come/go) Characteristics ( burn vs stab) Aggravating factors ( worse or better) Relieving factors ( medication- what makes it better) Treatment ( medication) Severity ( rate the pain)
Past Medical History
- childhood illness
- accidents
- serious chronic illnesses ( diabetes/cancer)
- Hospitalizations
- surgical history
- obstetrics history ( children
- immunizations
- allergies
- current medications ( dosage, route,)
Family History
HUGE PART IN KNOWING
age and health or cause of death of relatives
genogram
R.O.S. review of systems
- evaluate past and present health state of each body systems
- double check to see if anything was omitted in the HPI ( history of present complaint)
- evaluate health promotion practices
- order of systems is roughly head to toe
Obtaining a health history
review of systems every week
- medications and treatments
- health promotion
- same partner each week
Basic Equipment
Thermometer stethoscope sphygmomanometer scale visual acuity charts penlight measuring tape
Advanced equipment
ophthalmoscope ( red reflex this semester
otoscope on model ear
tuning fork
reflex hammer
Assessment techniques
IPPA inspection palpation percussion aucultation
Inspection
- ” concentrated watching”
- done first with assessment of each body system and is ongoing
- compare right and left side of body for SYMMETRY
- requires good lighting and adequate exposure
Categories:
indirect: assisted by equipment
direct: sight, hearing, smell
Palpation
TOUCH use calm gentle approach warm hands first Assess: texture temperature moisture organ location and size swelling ( EDEMA) Spasticity crepitation vibration pulsation presence of lumps or masses presence of pain or tenderness
Palpation: Fingertips
tactile discrmimination
texture, swelling, pulsations, determine presence of lumps
finger and thumb “ Pinching”
detects POSITION, SHAPE, and CONSISTENCY of an organ or mass ( the shape or presence)
Dorsa ( back of hand)
used for determining temperature
Skin on hands are thinner than palms
bad of fingers ( metacarpophalangeal joints) or ulnar surface of the hand detects vibration
Types of Palpation
start with light palpation to detect surfac characteristics 1. pulse 2. skin temp 3. texture 4. consistency 5. warmth 6. mobility 7. tenderness
deep palpation
for organ size
shape
rebound tenderness
abnormalities; tumors or masses
Percussion
” to strike”
- assess underlying structures
- assess location, size, and density of the organ
- detect tenderness ( sinus)
- Eliciting deep tendon reflex using percussion hammer
Methods or percussion: direct or immediate
hand or fingertips directly on the surface
nothing in between
indirect percussion
Mediate used more often uses both hands striking hands contact the stationary hand fixed on the person's skin yields a sound and subtle vibration
blunt percussion
ulnar surface of the fist
reflex hammer
Percussion notes characteristics: resonance
Lungs
clear hollow low pitched sounds
Hyperresonance
lungs
low booming longer sound than resonance
Tympany
Abdomen
Loud high pitched musical or drum like
dullness
dense organs
soft high pitched muffled
flatness
muscles, bones, solid mass
very soft high pitched dead stop of sound
Auscultation
Listen to sounds produced through the stethoscope
warm quiet room
avoid artifact
warm stethoscope end piece
rub in palm
NEVER LISTEN THROUGH A GOWN OR OVER CLOThING
Diaphragm
high pitched sounds
breath sounds
bowel sounds
and normal heart sounds
bell
low pitched sounds
extra hear sounds and murmurs
Auscultation determines…
Intesity
pitch
duration
recurring sounds
Order of Physical Assessment
Inspection, palpation, percussion, auscultation
abdomen physical assessment
Inspection
auscultation
percussion
palpation
infant physical assessment
inspection
auscultation
palpation
percussion
When Charting…..
- start at the beginning of the page with date and time
- immediately afterwards start documenting your findings
- end the paragraph with your first initial and last name and NSUA
- chart in pen only
- if error is made….then date and initial. some facilities require mistake entry or error
* ** follow protocol for wherever you work***
