Health Assessment Lecture 1

AIDET

acknowledge, introduce, duration, explanation, thank you

acknowledge

greet the patient by name, make eye contact, smile, and acknowledge family or friends in the room

introduce

introduce yourself with your name, skill set, professional certification, and experience

duration

give an accurate time expectation for tests, physician arrival, and next steps. When this is not possible, give a time in which you will update the patient on progress.

explanation

explain step-by-step what to expect, answer questions, and let the patient know how to contact you

thank you

thank the patient and/or family. You might express gratitude to them for choosing your hospital or for their communication and cooperation. Thank family members for being there to support the patient.

a few nursing definitions

- protection, promotion, and optimization of health and abilities

- prevention of illness and injury

- alleviation of suffering through the diagnosis and treatment of human responses

- advocacy in the care of individuals, families, communities, and population

- getting patients back to the "base-line"

how long has physical assessment been an integral part of nursing

since the 1800s

nurses rely on their senses to assess observing for:

- changes in color and temp, use of limbs, body output, muscle strength, and smell

the nursing process

Assessment

Diagnosis

Planning

Implementation

Evaluation

Assessment (nursing process)

collecting subjective and objective data

diagnosis (nursing process)

analyzing data to make a collaborative nursing judgment

planning (nursing process)

determining outcome criteria and developing a plan

implementation (nursing process)

carrying out the plan

evaluation (nursing process)

assessing whether the outcome criteria have been mer and revising the plan as necessary

what is the first and most critical phase of nursing

assessment

differences in assessments

holistic nursing assessment and physical medical assessment

holistic nursing

collects holistic (mind, body spirit) subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgement

physical medical assessment

focuses primarily on clients physiological status and on treatment

four basic types of assessment

Initial comprehensive assessment, ongoing or partial assessment, focused or problem oriented assessment and emergency or rapid assessment

initial comprehensive assessment (complete)

subjective and objective data

ongoing (partial) assessment

mini overview as a follow-up (reassessment)

focused (problem-oriented) assessment

Thorough assessment of a particular client problem, which does not cover areas not related to the problem, specific concern

emergency (rapid) assessment

immediate and prompt

preparing for health assessment steps

- review client's records

- review client's status with other health care team members if indicated

- educated yourself about client's diagnosis and tests preformed

- reflect on your own feelings regarding the client's information

- obtain and organize needed materials

the two most important patient identifiers

name and DOB

First major step in the Health Assessment

collection of subjective data

what does subjective data include

- anything they tell you

- biographical (name, age, religion)

- history of present health concern (physical symptoms related to each body system)

- personal health history

- family history

- health and lifestyle practices

- review of systems

second major step in the assessment phase

objective data

what does objective data include

- physical characteristics

- body functions

- appearance

- behavior

- measurements

- results of lab testing

third major step in assessment phase

validation of assessment data, ensure assessment isn't ended before all data is collected

fourth major step in assessment phase

documentation of data

- forms the database for all healthcare members

- ensures valid conclusions can be made

golden rule for documenting

if you didn't document it, it didn't happen

analysis of assessment data

- identify abnormal data and strengths

- cluster the data

- draw inferences and identify problems

- propose possible nursing diagnoses

- check for defining characteristics of those diagnoses

- confirm or rule out nursing diagnoses

- document conclusions

Four Phases of the Interview

pre-introductory, introductory, working, summary and closing

pre-introductory phase

review the client's medical record (aka "chart-check")

introductory phase

- introduce yourself to the client

- explain the purpose of the interview

- discuss the types of questions that will be asked

- explain the reasoning for taking notes

- assure the client that the information will remain confidential

- make sure the client is comfortable and has privacy

- develop trust and rapport using verbal and nonverbal skills

working phase

- biographical data

- reasons for seeking healthcare

- history of present health concern

- past health history

- family history

- review of body systems

- lifestyle and health practices

- developmental level

summary and closing phase

- summarize info obtained during the working phase

- validate problems and goals with the client

- identify and discuss possible plans to resolve the problem with the client

- ask if anything else concerns the client

- ask if there are any further questions

nonverbal techniques

- appearance (look professional)

- demeanor ( act professional)

- facial expression (neutral, appropriate)

- attitude (nonjudgmental)

- silence (allow time for reflection)

- listening (open mind and body positioning)

verbal techniques

- open-ended questions ( how and what )

- close-ended questions ( yes or no)

- laundry list (is the pain sharp or dull)

- rephrasing ( allows for clarification)

- well-placed phrases (uh-huh and yes)

- inferring

- providing information