Health Assessment - CH 1-5 + 8

clinical judgment

making observations and collecting data to make critical decisions regarding patient care

assessment

collecting subjective and objective data; 1st step of the nursing process

the nursing process

ADPIE

diagnosis

analyzing subjective and objective data to make and prioritize professional clinical judgments

planning

generating solutions, developing a plan, and determining which outcomes need to be met first

implementation

taking action. prioritizing and implementing the planned interventions

evaluation

assessing whether outcomes have been met and revising the plan if the interventions did not make a difference

comprehensive health assessment

collecting holistic subjective and objective data to determine a client’s overall level of functioning to make a professional clinical judgment

objective data

what we can see going on in the patient; we can assess this

subjective data

what the patient tells us is happening to them; we take their word for it

initial comprehensive assessment

creating a baseline for rest of the visit or future visits; health history, family history, lifestyle, health practices, medications, head-to-toe assessment

ongoing/partial assessment

data collection after initial comprehensive assessment; reassessment of findings in comprehensive in follow up of health status

focused assessment

performed when a comprehensive exists for the client who comes to the health agency with a specific concern

emergency assessment

very rapid assessment performed in life-threatening situations; ABCs

ABC

airway, breathing, circulation

analyzing cues

2nd step of the nursing process

data analysis

phase in which the nurse identifies and clusters the cues collected to make clinical judgements; identify client concerns, collaborative problems, or referrals

preintroductory phase

review of medical record before meeting patient

introductory phase

introduce, explain, ensure confidentiality, establish rapport or trust

working phase

nurse listens and observes cues and uses critical thinking skills to interpret and validate information received from the client

closing phase

summarize information, identifies and discusses possible plan, ask about any further questions

anxious client

provide simple, organized information in a structured format

angry client

approach in calm, reassuring, and in-control manner; allow to ventilate feelings; obtain help as needed

depressed client

express interest in understanding the client and respond in a neutral manner

manipulative client

provide structure and set limits; obtain objective opinion from other nursing colleagues

seductive client

set firm limits on overt sexual behavior and avoid responding to subtle behaviors; do not interact without a witness

COLDSPA

character, onset, location, duration, severity, pattern, associated factors

character

describe the sign or symptom

onset

when did this symptom begin

location

where is the symptoms? does it radiate?

duration

how long does this symptom last; is it reoccurring

severity

how bad is it and how much does it bother you; pain scales

pattern

what makes it better or worse

associated factors

what other symptoms occur with it

inspection

visually examining the body for color, size, shape, symmetry, odors, lesions, etc.

palpation

using touch to feel for texture, temperature, moisture, pulsations, tenderness, and masses

percussion

tapping on body surfaces to create sounds or vibrations that reveal underlying density

auscultation

listening to body sounds, like heart, lungs, or bowels with a stethoscope

moderate palpation

depressing skin surface with the dominant hand and using a circular motion to palpate

resonance

loud, low pitch, long duration, hollow

hyperresonance

very loud, low pitch, long, booming

tympany

loud, high pitch, moderate duration, thud-like

dullness

medium, medium pitch, moderate duration, and thud-like

flatness

soft, high pitch, short duration, flat

direct percussion

tap directly on client skin using fingers

blunt percussion

use heel of fist or blunt object to strike the back of their other hand that is placed on the client

indirect percussion

middle finger of one hand placed on client and use middle finger on other hand to tap

diaphragm

used to hear high pitch sounds

bell

used to hear low pitch sounds

validation

confirm or verify that the subjective and objective data collected are valid and reliable

documentation

promotes effective communication among multidisciplinary team members to facilitate safe and effective client care; provide legal record of care

EHR

intended to refer to the total health of the client; promote collaboration

SBAR

situation, background, assessment, recommendation

general survey

first part of the physical examination; will lead to cues about health status of client

normal pulse

60 - 100 BPM

tachycardia

> 100 BPM

bradycardia

< 60 BPM

SPO2

92% - 99%

elevated BP

120-129 mmHg and < 80 mmHg

stage 1

130-139 mmHg and 80-89 mmHg

stage 2

140 mmHg or diastolic at 90 mmHg

hypertensive crisis

> 180 mmHg and/or >120 mmHg

kyphosis

excessive outward curve of upper spine; hunchback