Introduction Introduction PhysicalPhysical

ExaminationExamination

Health Health AssessmentAssessment

Why do I need to Why do I need to know Physical know Physical Assessment?Assessment?

““What is your What is your reason for reason for coming here coming here today?”today?”

AssessmentAssessment

Collection of data about an Collection of data about an individual’s health state.individual’s health state.

Subjective DataSubjective Data Client historyClient history

Objective DataObjective Data InspectionInspection PercussionPercussion PalpationPalpation AuscultationAuscultation

Data BaseData Base

All the information; obj., All the information; obj., subjective, client’s record, lab, and subjective, client’s record, lab, and test resultstest results

Study and cluster dataStudy and cluster data DiagnosisDiagnosis Purpose of assessment is to make Purpose of assessment is to make

a diagnosis or judgementa diagnosis or judgement

Nursing ProcessNursing Process

ADPIEADPIE AssessmentAssessment DiagnosisDiagnosis (outcome identification)(outcome identification) PlanningPlanning ImplementationImplementation EvaluationEvaluation

Critical ThinkingCritical Thinking

Problem solving – the puzzle – the Problem solving – the puzzle – the big picturebig picture

Processing information – use Processing information – use theory learned, experience, theory learned, experience, intuition, intellectual and manual intuition, intellectual and manual skillsskills

Priority SettingPriority Setting

First level problemsFirst level problems ABC’sABC’s Vital SignsVital Signs

Second LevelSecond Level Mental Status changes (LOC)Mental Status changes (LOC) Acute painAcute pain Acute urinary eliminationAcute urinary elimination Untreated medical problemsUntreated medical problems Abn. Bld. ValuesAbn. Bld. Values Risks of infection, safety, securityRisks of infection, safety, security

Third Level PriorityThird Level Priority Knowledge deficitKnowledge deficit Activity, restActivity, rest CopingCoping

4 Types of Data Base4 Types of Data Base

1.1. Complete ( Total ) Complete ( Total )

2.2. Episodic or Problem CenteredEpisodic or Problem Centered

3.3. Follow – upFollow – up

4.4. EmergencyEmergency

Consideration of:Consideration of:

Developmental StatesDevelopmental States Cultural AssessmentCultural Assessment

Beliefs, values, practicesBeliefs, values, practices

The InterviewThe Interview

““Spend more time listening”Spend more time listening” Open /Closed ended questionsOpen /Closed ended questions InterpreterInterpreter

Family/ professionalFamily/ professional

Communication SkillsCommunication Skills

Collecting information with Collecting information with understandingunderstanding

Verbal/NonverbalVerbal/Nonverbal

Factors that impact on Factors that impact on CommunicationCommunication

InternalInternal Personal attributes – acceptance of Personal attributes – acceptance of

client (Nonjudgemental)client (Nonjudgemental) RespectRespect Empathy Empathy ListeningListening

Factors that impact on Factors that impact on CommunicationCommunication

External FactorsExternal Factors PrivacyPrivacy InterruptionsInterruptions Comfortable environment – temp., Comfortable environment – temp.,

noise, lunch, bloody mess noise, lunch, bloody mess

10 Traps of Inteviewing pg 10 Traps of Inteviewing pg 5757

1.1. False AssuranceFalse Assurance

2.2. Unwanted AdviceUnwanted Advice

3.3. Using AuthorityUsing Authority

4.4. Avoidance language – dead is deadAvoidance language – dead is dead

5.5. Engaging in distance “the Friend” Engaging in distance “the Friend”

6.6. Professional jargonProfessional jargon

7.7. Leading or biased questions; “you Leading or biased questions; “you don’t…?”don’t…?”

8.8. Too much talkingToo much talking

9.9. InterruptingInterrupting

10.10. Why? Why?

Threat of Violence!!!!Threat of Violence!!!!

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