physical assesmsnt quiz 1

5 phases of nursing process

1) assessment - gather data

2) diagnosis - identify problem

3) planning/outcomes - create nursing interventions, goals, objectives

4) implementation - carry out the plan

5) evaluation - gather data to determine if goals of achieved and revise plan of care

THINK ADPIE

Clinical judgment measurement model

1) recognize cues

2) analyze cues

3) prioritize hypothesis

4) generate solutions

5) take action

6) evaluate outcomes

Main steps of nursing process and CJMM

Assessment for nursing process and recognizing and analyzing cues for CJMM

Health assessment

SYSTEMATIC method of collecting data including both subjective and objective

3 parts health assessment

1) interview: health history

2) physical assessment : observed and measured

3) documentation

Read what to really understand what is going on with a patient

The most recent history and physical report in their chart

Health history

Based on their own perceptions of the clients health

Most important part of assessment process

INTERVIEW

Barriers to effective client interactions

1) false reassurance

2) interrupting or changing the subject

3) passing judgement

4) cross examination

5) using technical terms

6) sensitive issues

Medical documentation emphasizes

Clarity, efficiency, for other health care professionals

Components of health history

1) identify data/ biographic data

2) chief complaint

3) history of present illness

4) past medical history

5) social history

6) family history

7) psychosocial history

8) review of body systems

chief complaint

symptom and length of duration

Ex: chest pain x6 days

History of present illness

More detailed of chief complaint; use OLDCART and ICE

OLDCART

O: onset

L: location

D: duration

C: characteristics

A: aggravating factors

R: relieving factors

T: treatment

ICE

I: impact on ADLs aka activities of daily living

C: coping strategies

E: emotional response

Pain Assessment PQRST

P: provokes, palliates, what makes it better or worse

Q: quality like stinging, dull, burning

R: location and Radiation

S: severity on scale 1-10

T: timing

Pertinent negatives

Clinical findings that are absent relative to the patients chief complaints like no fever, no chest pain; INCLUDE IN HISTORY OF PRESENT ILLNESS

Three things required of current medication

Dose, frequency, route

Family history

CA, CVA, DM, HTN, CAD; if no have state negative

Review of body systems is what and not what

An interview not a physical exam

Subjective vs objective assessment gathering

Subjective is info from the clients pov and objective is observable and measurable data through physical exam/ physical assessment

Four basic techniques of physical exam

1) inspection

2) palpation

3) percussion

4) auscultation

Inspection

Skill of observing client in deliberate and systematic manner using color, size, shape, symmetry

Palpation

Skill of assessing patient through TOUCH

Percussion

Strike of tap on a body part with fingers to produce an audible sound

Auscultation

Sounds produced by body, always auscultate UNDER CLOTHES