Introduction to Health Assessment

Assessment

nurse gathers info from client through interview, physical exam, and observation. Subjective and objective data

Analysis

uses clinical judgment to make out the data collected, collaborates with client to develop plan of care identifying actual and potential problems

Planning

nurse uses problem solving and decision making skills to prioritize care. Outcomes and goals and develops interventions to meet these goals

Implementation

carry out interventions that have been established. Clinical judgement to monitor clients progress towards achieving their goals

Evaluation

ongoing part. To see effectiveness and achievability of goals and need for adjustment of the intervention

Contextual awareness

understanding status of client and the events that have led to their interactions with the health care team

Analyzing assumptions

nurse evaluating clients clinical situation and using critical thinking to use or modify standards approaches to meet the specific health needs and concerns of the client

Exploring alternatives

use of holistic approaches for treating the whole person

Using credible sources

using faculty standards like policy and procedures manuals state and federal health care standards

Reflecting and deciding

self reflection, reflection on clients goals, decide interventions with client input, aware of appropriate methods of communication

Ethical principles

nonmaleficence, beneficence, autonomy, justice, confidentiality

Nonmaleficence

avoiding hurt or harm to others

Confidentiality

protecting the privacy of others

Beneficence

helping others in a positive manner

Justice

being open and fair

Autonomy

having self control

ISBARR

identity, situation, background, assessment, recommendations, read back orders

Identity

state the team members name and title

Situation

provide the circumstances that have required the communication to occur

Background

provide the background data regarding the client to assist the provider with familiarity

Assessment

provide the most recent set of vital signs to other data relevant to the communication

Recommendations

provide any suggestions that may be helpful to the situation

Read back orders

repeat the orders that are given and clarify anything that is unclear

Auscultation

listening to the sounds of the heart, lung, stomach, intestines, and arteries, stethoscope, doppler

Inspection

looking carefully and thoroughly at client, penlight, tape measure, pulse ox, stadiometer (height)

Palpation

act of using dorsal surface or fingertips to feel areas of the body for various findings, temperature, moisture, or unexpected findings that may have been noticed during inspections

Percussion

advanced skill tapping of clients skin w/ short quick motion to determine vibrations and sounds depending on underlying structure or organ that is percussed. Helps determine density of area, theater it is fluid filled, air filled, or solid

Tools for assessments on the chest

auscultate, stethoscope, and inspect

Tools for assessment on abdomen

palpate, auscultate, inspect, stethoscope, tape measure

Tools for assessment on eyes

inspect, penlight, palpate

Tools for assessment on feet

doppler, palpate, inspect

Doppler

ultrasound device

Subjective data

feelings and concerns from the clients point of view, documented using quotation marks