HA Week 1

Health Assessment and the Nurse - Tone, intensity
- Speed
You are working in the emergency department (ED)
 Action/ kinetics cues:
when the father comes in with his 9 years old daughter.
- Body movements
He stated that she fell off her bike and hit her head.
- Posture, arm position
 Assessment - Hand gestures
A deliberate and systematic form of data - Facial expression, eye contact
collection.  Object cues
 Purpose: To determine - Your appearance is equally important
- Clients current and past health status - Grooming and dress should be
- Functional status appropriate for the situation
- Clients present and coping patterns  Personal space
- The territory surrounding a person that
Nursing process he perceives as private; or the physical
The nursing process is a systematic problem-solving distance that needs to be maintained
method, a rational method of planning and providing for the person to feel comfortable.
nursing care. It is a continuous process Define by: culture and situation
 Four distinct zones
 Assessment - Intimate (0-2 ft.)
- Most important step - Personal (2-4 ft.)
- Sets the tone for the rest of the process - Social (4-12 ft.)
- Method to establish baseline - Public (more than 12 ft.)
 Diagnosis  Touch
 Planning - Feeling, anger, caring is conveyed thru
- Setting goals and outcomes touch
 Implementation - Person’s responds to touch depends on
 Evaluation trust formed within a relationship.
 Communication techniques
Purpose of NP
- Affirmation
A. Identify actual potential health problems Acknowledges patient’s response
B. Provides a framework in which to practice - Silence
nursing Allow patient to collect his thoughts
C. Deliver specific nursing interventions to - Restating
address those needs Helps clarify and validate what the
patient has said
Types of Assessment  Active listening
 Comprehensive Conveys interest and acceptance
Thorough and detailed health history and  Broad and general openings
physical examination. Examines patient’s Effective when you want to hear what is
overall health status. important to your patients. Use open-ended
 Focused questions.
Problem-oriented, perform on an on-going How you communicate
basis to monitor and evaluate patient’s
progress, intervention, and response to  Genuineness
treatment. Be open, honest, and sincere with your
 Communication patients.
 Respect
Is a process of sharing information of showing Everyone should be respected as a person of
information and meaning, of sending and receiving worth and value.
messages?  Empathy
 Communication Understanding how she or he feels
- Verbal Assessment skills
- Nonverbal
 Vocal cues  Interpersonal/ Affective skills
- Quality of voice Assessment is a “feeling” process.
 Affective skills are needed to develop caring,  Secondary data source
therapeutic nurse-patient relationship  Family members
- The quality of assessment depends on  Friends
the relationship you developed with  Other health care providers
your patients  Old medical records
- Establish trust and mutual respect is
essential before you begin the Methods of Data Collection
assessment.
A. Interview
Cognitive Skills  Directive
Structured with specific questions, and
 Assessment is a “thinking process” controlled by the nurse. Require less time,
 Critical thinking very effective for obtaining factual data.
- Is reflective, reasonable thinking. It is  Non-directive
not just doing, it is asking “why?” it Controlled by the patient, very effective at
involves inquiry, interpretation, eliciting patient’s perception and feelings.
analysis, and synthesis. Required more time.
 A scientific method of problem solving
 Needed in clinical decision making Phase of the Interview
Psychomotor Skills  Introductory phase

 Introduce self
 Skills needed to perform the four techniques of  Explain purpose of interview
physical assessment. Most important skill  Explain time frame
- Inspection  The Working Phase
- Palpation
 Data collection, structured
- Percussion
 Longest phase
- Auscultation
 The Termination Phase
Ethical skills  End of interview
 Summarize restate findings
 Assessment is being responsible and
B. Observation
accountable.
 Use all of your senses
 Responsible & accountable for your
 Look at patient and environment
practice
 What data can you collect through
 Patient advocate
observation?
 Respect patients’ rights
C. Physical Assessment
 Assure confidentiality
 Inspection
Involves looking at your patient and compare
her or his appearance with what you know as
A. Data Collection normal.
 Subjective  Palpation
Covert, not measurable symptoms. Referred to Examination with the hands, feeling for organs
as “symptoms” and masses.
 Thoughts  Light
 Beliefs Use to assess surface characteristics
 Feelings (1”)
 Sensation  Deep
 Perception Organs and masses (2-3”)
 Objective  Percussion
Overt, measurable. Referred to as “signs” Tapping a body surface area to determine the
 Physical exam density of a part by the sound it produce.
 Diagnostic studies Elicit area of tenderness
 Auscultation
Sources of Data
Listening to the sounds made by various body
 Primary data source. structures through a stethoscope.
 Patient B. Validating Data
 Compare subjective and objective data.
 Ask patient to validate assessment data.
 Use other sources to validate data.
 Family members
 Healthcare providers
 Old records
 Diagnostic tests
C. Organizing/Clustering Data
Cluster Data
 Maslow’s hierarchy of needs
 Roy’s adaptation theory
 Gordon’s functional health patients
D. Prioritizing data
Primary or Top Priority
Life- threatening problems
 Airway
 Breathing
 Circulation
Secondary
Problems affecting basic needs requiring prompt
attention to prevent deterioration in patients’ condition.
(Pain)
Tertiary
Problems affecting psychological needs (anxiety, fear,
loneliness)
 Documenting Data
Methods
 SOAPIE
 DAR
 NARRATIVE

HA Week 1

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Health Assessment and the Nurse - Tone, intensity

Psychomotor Skills  Introductory phase

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