W1: Health Assessment Flashcards
What is Health assessment?
- Refered to as a collection of subjective data ( how the pt is feeling) and objective data ( physcial assesssment, general survey, head to toe assessment, vitals) involved in a paitents heath history.
- Aim to create personalized paitent centere careing plans done from a intradisiplinary approach and make clinical judgements.
ADPIE
Foundational aspect to nursing pratice and client assessments. Conducts interaction and maximizes an ogranized approach to care plans.
Composed of Assessment Nursing Diagnosis Implementation Evaluation
What is the nurses role in assesment?
Nurses role is to be a communicator and document our findings. Using evidence based assessments and find the baseline levels, how are a clients ADL’s being effected and idenifty coping skills.
Essential Parts to Assessment
- Therapuetic communication, open ended questions and buidling up that rapport. Find the underlying issues, access risk factors and create health promotion.
Health Promotion
Empowering to take control over health
- Screening for history ( focused questions)
- Primary- secondary, teritary prevention
Compare current with past medical status, what can they no longer do and how can we help assess.
Primary Prevention: Aims at health promotion and empowering to take control, ex( exceirse, diet)
Secondary: Diease prevention so vaccines or screening
Teriatry: rehabiliation limit symptoms
what is evidence based assessment?
- Should inform clinical descions regarding health and guide nursing descions. Best pratice techniques, examination. CNA is defined as information acquired through research and scientific evaluation of practice. Assessment skills are foundational
Importance of questioning tradition in assessment when no evidence exists to support.
ADPIE Assessment
Gathering objective and subective data
- ADPIE assessment
- evidenced based plan, diagnosis,
- Analyze the alternatives and how to communiate
Document findings
When to document?
Always document the needs, change in clients condition, reassess after interventions , side effects.
Assessment IPPA
Inspection
Palpation
Percussion
Auscultation
Inspection
Use eyes to view expressions, behavior, what you obsereve. Visual, auditory, olfactory sense
1. General Inspection ( general survey) obervable cues for assessment.
2. Location Inspection ( body systems): color, lesions, movement, contour, symmetry, accessing subjective data and verbal/nonverbal Assess if subjective (verbal , nonverbal data) agrees with the inspection.
Palpation
Gentle poking, use of touch, temperature, sensations, kineesthetic
1. Light: skin is depressed to depth of 1 cm
2. Deep: Skin is depressed to a 3-4 cm in circualr motions, dripping motions, direct pressure, gliding motions, grasping.
Palptation Techniques
Finger pads–> texture, moistures, conttour, consitency, vibrations
Fingerprints / Pads–> Fluid content of tissues , elastic pulses, thickness, vasucularity, swelling, lumps, palptate tender last
Dorsum and ulnear edge: temp.
Ulnear edge: vibrations
Percussion
Tapping of surface
- Tympany, ressonace, hyperresonace , dullness
- Tapping by nurse produces sound to be interpreted
1. Direct: tapping body surface , direct to examine sinuses
2. Indirect: storking exmainer hand or finger on surface
Auscualtion
- Various body sounds: cardiac, respiratory, abdomen
Stethoscope: best quality bell low pitch, diaphram high pitched sounds. - Hold still, quite area
- Bell: low frequrncy sounds
- Diaphram: higher sounds
First Level
First level or emergent probelms are life-threatning and are Airway breathing circulation, vitals.
Second level
Urgent , necessitating prompt intervention (acute)
Third
Stable, important addressed are more urgent issues emergent, urgent, stable
Emergency Assessment
Urgent situations needing life saving measures to occur. Unstable airway, breathing, circulation, Asssess and intervene together . Open airway, arit resp, CPR, pain, protect.
Overdose ‘what did you take!”
Problem Centered
Focused on client’s issues and the main complaint. One issue or body system in detail and includes general survey, vitals, assessment of one system.
Comprehensive
Completes health history of past and current
Strength, risks, function abilities, health education, physical exam, all body systems. Annually for primary care setting outpaietnts, following admission to facility.
Parts to Health Assessment
1) General Survey: nurses observations
2) Subjective Data History
3) Objective Data ( vitals, assessment)
Objective data
Data gathered from pure oberavations and documentation from the nurse ( temperature, MP, signs)
Subjective data
Stated, what the client says “ i can’t breath or my head hurts” symptoms that the client feels. Focused questions used to determine IPPA required.
Onset of problem/symptom
• P: Provoking/Palliating
• Q: Quality
• R: Region/Radiation
• S: Severity
• T: Timing
• U: Understanding
V: value
Body position
anatomical, facing erect, straight
Whether prone or supine imagien paitent in this position