Purpose Flashcards
Purpose
-gather baseline data about the client’s health
-supplement, confirm, or refute previous data
-confirm and identify nursing diagnosis
-make clinical judgments r/t changes in data
-evaluate psychological outcomes of care
Interview
Types of data:
-subjective: pt description of things
-ex. Pain
-objective: measurable, observable
-ex. Temp, bp, blood sugar, color of urine
Interview
Sources of data:
-primary: from pt
-secondary: family, friends, medical record, health personnel
Diagnostic tests
Laboratory
-ABG’s, CBC, sputum
Diagnostic tests
Radiologic
-chest X-ray, CT, V/Q scan, PET scans
Diagnostic tests
-skin tests
-pulmonary function tests
-endoscopy examinations
Methods of data collection
-interview:
-orientation phase
-working phase
-termination phase
Methods of data collection
Nursing health history:
-recent hospital
-family history
-smoking or drinking
Methods of data collection
-physical examination
-diagnostic and laboratory results
Types of physical assessment
-comprehensive
-focused
-system specific
-ongoing
-all assessments are considered HEAD to TOE
Elements of assessment
History:
-baseline history
-problem based-history
Elements of assessment
Examination:
-vital signs
-inspection
-auscultation
-palpation
Techniques for assessment
-inspection(visual)
-palpation(feel)
-percussion
-auscultation(listen)
-olfaction(smell)
Inspection (visual)
-Good lighting
-Expose all of part to be examined; drape or cover parts not being examined for privacy
-Use additional lighting/devices for some areas of body; eyes, ears, throat
Inspection cont.
Observing for:
-color
-shape/symmetry
-movement
-position
