Physical Assessment Exam 1 Lecture 1

What is health assessment and what is it used for?

Systematic method of collecting and analyzing data. Used to create a patient-centered plan-of-care.

What is assessment?

Collection of data on the patients health

What is diagnosis?

Analyzing the assessment data to determine actual/potential diagnoses, problems or issues.

What is outcome identification?

What the expectation is with the plan of care.

What is planning?

Develop a plan of how to achieve the outcomes.

What is implementation?

Coordinate the care of the patient and promote health and safety.

What is evaluate?

What the goal achieved? Or is there progress toward the goal.

What are the 4 primary components of a health assessment?

Health history, physical exam, review other data from health record, and documentation.

What do you do during a health history?

Why is the patient visiting today, what are their symptoms and what the patient describes or tells you (subjective data).

What do you do during a physical exam?

Look for signs and what did you observe/assess (objective data).

What do you do when reviewing other data from the health record?

Look at other labs, procedures, and check notes from social work.

What do you do during documentation?

Document what happened during the health assessment into the EHR. This is the legal permeant record that should have JUST facts.

What is a symptom?

What the patient feels/communicates (subjective).

What is a sign?

Clinical findings collected during a physical exam (objective).

What are clinical manifestations?

Describes the presenting signs and/or symptoms experienced by the patient.

What is included in a health history?

Feelings or experiences with their history/illness, current meds, previous illness or surgeries, family history, personal and psychological history, basic review of systems.

What is the order of assessment?

Inspection, palpation, percussion, and auscultation.

What is the purpose of documentation of data?

Improves efficiency and increases the accuracy of communication. Improves plan of care, legal document of care received, and baseline for evaluation.

What are the benefits of EHR?

Orders can be entered, lab and diagnostic testing results, documentation of procedures, progress notes, plan of care, allows client to assess the record, and direct communication between client and health team.

What does context of care mean?

Circumstances or situation related to health care delivery, may be related to setting or environment, and may be related to physical, psychologic, and socioeconomic circumstances.

What does patient need mean?

Why is the patient seeking care? What type of assessment was performed by the provider.

What should be done while examining the skin?

Inspect the skin for color, temperature, lesions, wounds, tugor.

What should be done while examining HEENT?

Inspect face, oral cavity, assess hearing based on conversation, inspect external eyes, and inspect pupils and response to light/accommodation.

What should be done while examining the chest/lungs?

Inspect chest and evaluate breathing effort. Auscultate lung sounds.

What should be done while examining the cardiovascular system?

Auscultate heart sounds and apical pulse, palpate distal pulses, palpate and inspect nails (capillary refill), inspect and palpate extremities for edema, and palpate for temperature, skin color, and hair growth.

What should be done while examining the muskuloskeletal system?

Inspect upper and lower extremities for size and symmetry, palpate extremities for tenderness, observe range of motion (ROM), assess muscle strength and gait.

What should be done while examining the abdomen?

Inspect and listen for bowel sounds, palpate the abdomen lightly. Start with the least hurtful area first.

What should be done while examining neuro?

Assess mental status and level of consciousness, and evaluate speech.

What should be done while examining the genitalia?

Inspect both male and female.

What is a comprehensive health assessment?

Detailed history and physical exam performed at the onset of care.

What is a focused assessment?

Specific problem on complaint.

What is an episodic/follow up health assessment?

Checking on a problem that was already identified to see if the intervention worked.

What is a shift assessment?

Hospital admission; check patient to see of there has been a change in status from baseline.

What is a screening/evaluation assessment?

Focused specifically on a disease detection.

What do you do with the data that was gathered?

Organize the data to clarify the problem, analyze expected and abnormal findings, and make a plan.

What are the 4 parts of clinical judgement?

Noticing, interpreting, responding, and reflecting.

What is health promotion?

Behavior motivated by desire to increase well-being and actualize health potential.

What is health protection?

Behavior motivated by desire to avoid illness, detect early illness, and maintain functioning when ill.

What is a primary prevention?

Prevent disease or injury BEFORE it occurs and promote a healthy lifestyle.

What is a secondary prevention?

CONDUCT health screening for early disease detection. Promote early diagnosis and prompt treatment to prevent complications.

What is a tertiary prevention?

Minimize effects of acute or chronic disease, provide better quality of life within limitations, provide rehabilitation, and support chronic disease management.

What does ABC’s stand for?

Airway, breathing, circulation.

What should you do when initiating the encounter with a patient?

Review the clinical record PRIOR to going into the patients room, prepare for an interview, make the setting private, quiet, and comfortable, and greet the patient and yourself.

How would you do the interview?

Nurse facilitates discussion to determine patients beliefs on how the define health, beliefs about maintaining health, view of responsibility of health, health behaviors, and unhealthy behaviors, and health expectations based of life experiences.

What are the 3 phases of the interview?

Introduction, discussion, and summary.

What is therapeutic communication?

The art of obtaining information and listening carefully. Ask one question at a time and wait for a reply, be attentive to patients feeling that may indicate need for additional data, some areas of questioning are sensitive, and seek clarification if needed.

What are some factors affecting therapeutic communication?

Physical setting, nurse behaviors, types of questions asked and how they are asked, personality and behavior of patients, how patient is feeling at the time of the interview, and nature of information being discussed or problem being confronted.

What is an open-ended question?

Encourages an open response by the patient and focus on questions about the patients health.

What are close-ended questions?

They are direct and causes the patient to focus on one set of thoughts. Often used in reviewing of systems and evaluating functional status.

If the patient has a language barrier, who should you recruit on your team?

A certified translator. A family member can give you false information.

What is active listening?

Shows patients they have your undivided attention. Spend more time listening than talking.

What is guided questioning?

Show your sustained interest in the patients concerns. Move from open-ended questions to focused questions.

What are empathetic responses?

Express empathy, first recognize the patients feelings, then actively move toward and elicit emotional content.

What is summarization?

Give capsule summary of patients story during the course of the interview. Clarify with the patient.

What is partnering?

Express your commitment to an ongoing relationship. Helps the patient feel that no matter what happens you will continue to provide their care.

What is validation?

Another way to affirm patient is to validate the legitimacy of emotional experience.

What is empowering?

Support patients in asking questions and being more involved with their care will lead to more patient involvement and success moving forward in their care plan.

What should you do if a patient is very talkative?

Focus on what’s most important to the patient for 5-10 minutes then redirect. Use more close-ended questions.

What should you do if a patient is crying?

Postpone further questioning until the patient is ready. A compassionate response enhances the relationship.

What are the health history demographics?

Name, address, contact, age, birthdate, gender, race, relationship status, occupation, insurance, emergency contact, family/who lives at home, advance directives (DNR, health care proxy).

What does the chief concern/complaint mean?

Why the patient is here. A brief statement in the clients own words of the reason they are seeking care.

What does OLD CARTS mean?

O-onset

L-location

D-duration

C-character

A-aggravating or alleviating factors

R-radiation

T-timing

S-severity

Why should you know about a patients family history?

It helps identify genetic, familial and environmental factors that might affect current or future health status. Know the first degree relatives (grandparents, parents, siblings, children, aunts, uncles).

Why should we do a physical exam?

Helps identify changes in the patients body systems. Do a head-to-toe assessment during this time.

What is the goal of explaining and planning for a patient?

Assess and respond to the patients needs for information. This can introduce choices and provide options.

What should you do when closing the interview?

Do not bring up new topics and make sure the patient is aware of mutual plans you have developed. Summarize the data with the patient to ensure everything is correct.