Week 1: Holistic Health Assessment (HHA) and Clinical Judgement Model (CJM) Flashcards
holistic health assessment
assessing an individual by looking them as a whole (physiological, psychological, sociological, developmental, spiritual and cultural needs of the client)
It is used to collect information, determine a plan of action, evaluate outcomes, etc.
context for health
for the patient:
- social determinants of health
- family context
- community context
for the nurse:
- positioning
- school of nursing core tenets (providing care that is safe and respectful of the individual, accepting of all races, ideas, beliefs, etc)
OLDCARTSS
presenting concern
Onset Location Duration Characteristics Alleviating factors and Aggravating factors Radiation Timing Severity Social determinant
Nursing health history
- presenting concern (OLDCARTSS)
- past medications
- family history
- current medications (prescribed and not)
- immunizations
- allergies
- lifestyles
- psychosocial
- impact on function
why is a physical important/why do we do it
- to get a base line of health
- to supplement, confirm, refute data
- help plan of care
- evaluate outcomes
- clinical judgements about health status
what is a head to toe assessment
looking at the body systems starting from the top of the head to the bottom
note that whenever documenting, all documents should be done from head to toe too.
- general survey
- vital signs
- skin/dermatological
- HEENT
- respiratory system
- cardiovascular system
- peripheral vascular system
- Gastrointestinal system
- genito-urinary system
- sexual/reproductive health
- musculoskeletal system
- neurologic system
- mental health
- cognition
- nutrition/fluid balance
4 basic techniques of physical assessment
- inspection (always done first)
- palpation
- percussion (tap tap)
- auscultation
Inspection
using senses (vision, hearing, smell) to observe
How:
- expose only the body parts being observed
- always LOOK before touching
- use good lighting
- provide a warm, private room
- observe: colour, size, location, symmetry, movements, odours and sounds
Palpation
touch and feel to determine:
- texture
- temperature
- moisture
- motion
- consistency of structures (solid/fluid)
Percussion
tapping the body to elicit tenderness or sounds
sounds vary on density (air, fluid, solids)
can determine: size, location
Auscultation
listen with stethoscope
- pitch
- duration
- intensity
- quality
diaphragm = high pitch sounds (breath, heart, bowel)
bell = low pitch (abnormal heart sounds, heart murmurs, bruits)
clinical judgment model
thinking like a nurse
noticing
critical thinking
clinical judgment
questions like:
- what do I know about the patient?
- what do I notice about the environment?
- How does my own past experience influence my decision making for patient care?
- how do nurses know what to do?
a nurses knowledge, experience, ethical perspective, knowing the patient gives EXPECTATIONS which goes to NOTICING which goes to INTERPRETING which goes to RESPONDING which goes to REFLECTING which could go back to INTERPRETING or back to the start with a new situation
clinical judgement (Tanner, 2006): an interpretation or conclusion about a patient’s needs, concerns, or health problems and or the decision to take action (or not) use or modify standard approaches or improvise new ones as deemed appropriate by the patient response
General Survey ASEPTIC
Appearance and behaviour Speech Emotion Perception Thought process Insight Cognition
