Week One Flashcards
What are the 4 Types of Assessment?
1) Problem-Centred or Focused Assessment
2) Follow-up Assessment
3) Baseline or Comprehensive Assessment
4) Emergency Assessment
Determining which physical assessments to perform depends largely on what…?
Subjective Data & the patients presenting symptoms
Types of Assessments: Problem-Centres or Focused Assessment
- Typically focuses on one or two main systems and is broader than the emergency assessment
- The nurse collects subjective data that are relevant to the presenting problem and focuses the assessment on the patients concerns
- Used in home care, primary care, long-term care facilities, and hospitals when nurses are trying to determine the status of a patient’s symptoms or concerns
- Listen to your patient! What are they telling you…?
Types of Assessments:
Follow-up Assessment
- This assessment allows the nurse to compare the patients current state to his or her previous health status
- This assessment can occur as a follow-up to a treatment or intervention to evaluate if implementing them worked
- The nurse should consider… “Is the patient better or worse compared with the last assessment?”
“Are further assessments or treatments required?”
Types of Assessments:
Baseline or Comprehensive Assessment
- Entails a complete health history along with a full physical examination
- It is intended to establish a baseline of the patients past and current health status and serves as a comparison for all future assessments
- Establishing a baseline assessment makes it easier for the nurse to identify when a change has occurred
- As a result, the nurse would want to include an assessment of the patient’s health history including illnesses, vaccinations, medical treatments, surgeries, and current medications
- When new admissions arrive
Types of Assessments:
Emergency Assessment
- Airway, breathing and circulation
- close ended questions and focused to determine what intervention is needed
What are the 4 Essential assessment techniques that are used in physical examinations? (IPPA)
1) I - Inspection
2) P - Palpation
3) P- Percussion
4) A- Auscultation
When does “Inspection” begin? (IPPA)
Begins with the first moment of interaction between the nurse and the patient
In “Inspection” what senses does the nurse use? (IPPA)
- Sight
- Hearing
- Smell
What does an “Inspection” of the patient mean? (IPPA)
- An intentional observing for specific characteristics of the patient
- The general inspection, sometimes also referred to as the “general survey”
When doing an “Inspection” what 4 things is the nurse meant to observe on the patient? (IPPA)
1) Appearance (physical assessment. –> Skin colour, symmetry, visible signs of distress)
2) Behaviour (is the client behaving appropriately for the situation? LOC AxOx4?)
3) Mobility (ROM)
4) Body Structure (Look at their body size and their shape)
What is always essential to obtain and do prior to touching the patient?
Always obtain CONSENT & protect their PRIVACY (ie., Pull curtains)
When would you NOT use palpation on a patient? (IPPA)
Do not palpate if an individual comes in with Acute abdominal pain (ex. appendicitis, ovarian cyst etc., could rupture when pushed on)
What parts of the hand does a nurse use when palpating a patient? (IPPA)
Use palm (ex. moisture) and dorsal (ex. temperature) of hand
The nurse assesses the size and position of a body part using the palmar surfaces of the fingers and finger pads. The nurse should use his or her fingertips to assess the texture, vibration, or pulsations.
What are the 2 different types of palpation? (IPPA)
1) Light Palpation
2) Deep Palpation
What is the depth is of Light Palpation? (IPPA)
1cm
