evidence based assesment and assesment techniques and safety

5 components of nursing process

assessment, nursing diagnosis, planning, implementation, evaluation

Avoid Assessment Traps

Approach problems in nonjudgmental way

Avoid making assumptions

Identify which information taking for granted or

overlooked based on natural assumptions

Cluster related items

Treat the client not the monitor

first level priority (ABC)

Emergent, life threatening, immediate

second level priority

Next in urgency, requiring attention so as to avoid further deterioration

third level priority

Important to patient's health but can be addressed after more urgent problems are addressed

outcome must be _____ when dealing with implementations

measurable

types of pt data

Complete Database (Physical Exam) - head-to-toe

Focused or Problem-Centered Database

Follow-up Database

Emergency Database

physical assessment consists of

inspection

Palpation

Percussion

Auscultation

general inspection begins with

Physical Appearance

• Body Structure

• Mobility

• Behaviors

Palpation techniques: fingertips

skin texture, swelling, pulsation, determining presence of lumps

Palpation techniques: fingers and thumb

detection of position, shape, and consistency of organ or mass

Palpation techniques: dorsa of hand and fingers

temp

Palpation techniques: base of fingers or ulnar surface of hand

vibrations

Tympanic: quality and example

Drumlike

Gastric bubble

Hyperresonant

Boomlike

Emphysematous lungs

Resonant

Hollow, Healthy lung tissue

Dull

Thudlike, Over liver

flat

very dull, over muscle