Week 1

2 types of assessments

objective and subjective

Objective assessments

Findings observed or measured by the clinician

Subjective assessments

Information shared by the patient

Patient database

subjective and objective data (records, laboratory results and diagnostic tests)

5 phases of the nursing process

assessment → nursing diagnosis → planning → implementation → evaluation → start cycle again

Assessment

Collect, validate and document data

Nursing diagnoses

Identify needs, risks and strengths

Planning

Set goals and select nursing interventions (dont need to agree with interventions, but need to make a plan)

Implementation

Deliver and document care

Evaluation

Review outcomes and adapt care

Clinical reasoning

1. validate: identify assumptions and validate data

2. compare: distinguish normal from abnormal findings

3. connect: cluster related cues and identify patterns

4. check: recognize inconsistencies and gaps

5. prioritize: set first-, second-, third-level priorities. identify collaborative problems

Why evidence-informed decision making matters

• Uses best evidence + clinical experience + patient values

• Improves care decisions & outcomes

• Integrates evidence, clinician judgment, patient context, and assessment findings.

Expanded concept of health

• Biomedical, behavioural, and socioenvironmental models

• Social, economic, and political conditions shape health

• Health promotion = enabling control over determinants of health

• Includes disease prevention and equity considerations

Diagnostic reasoning

• Attend to cues (signs, symptoms, labs)

• Formulate diagnostic hypotheses

• Gather data related to hypotheses

• Evaluate hypotheses

  → Final diagnosis

• Important: validate data for accuracy and completeness

Relational Approach

• requires understanding people within their lived context.

• Context shapes health & illness: Social, cultural, family, historical, and personal contexts influence health and illness.

• Examine key dimensions: Consider intrapersonal, interpersonal, and contextual dimensions.

• Practice reflexivity: Reflexivity = observation + scrutiny + conscious participation.

Four types of assessments

• complete

• episodic

• follow-up

• emergency

Complete assessment

Full history and physical examination

Episodic assessment

Focus on a specific issue

Follow-up assessments

Reassess identified problems

Emergency assessments

Rapid collection during a crisis

General survey & vital signs

• Physical appearance

• Mobility

• Body structure

• Behaviour

Before the examination happens what should you be aware of?

Infection control: Begin with a clean field and a safer environment.

1. Prepare the field: Equipment and shared surfaces

2. Protect people: Hand hygiene and precautions

Create a clean field

• Clean the stethoscope

• Separate clean and used items: Maintain distinct areas for examination equipment.

• Clean shared equipment: Consider everything carried from patient to patient. *curtains; doorhandles; bedspaces

How do you create a safer environment?

• Hand hygiene: Use proper handwashing practices.

• Protective equipment: Gloves, masks, gowns and protective eyewear.

• Precautions: Routine practices and transmission-based precautions.

The general survey: four areas to observe

Begin observing when you first meet the patient

• Physical appearance: Age, consciousness, skin colour and signs of distress

• Body structure: Stature, symmetry, posture and body build

• Mobility: Gait and range of motion

• Behaviour: Expression, mood, speech, dress and hygiene

Recognize age-related variation

• Children: Observe child-adult interactions. Notice unexpected behaviour.

• Older adults: Changes in posture, appearance and mobility. Examples: spinal flexion and a wider gait.

Four skills of physical examination (IPPA)

• Inspection: Look

• Palpation: Feel

• Percussion: Tap

• Auscultation: Listen

• Sight • smell • touch • hearing

  • Technical skills + knowledge

  • Developed through practice

Inspection

• Observe carefully: Concentrated watching* and close scrutiny.

• Compare both sides: Look for symmetry between right and left.

• Make the area visible: Use good lighting and adequate exposure.

Examples of instruments used for inspection

Otoscope • ophthalmoscope • specula • penlight

How to palpate?

• Slow and systematic

• Light and deep palpation

• Intermittent pressure

What can touch tell you?

• Texture, temperature and moisture

• Swelling, lumps or masses

• Vibration or pulsation

• Tenderness or pain

Percussion

• Short, sharp taps create vibration and characteristic sounds.

• Assess the location, size and density of underlying structures

Indirect percussion

Stationary hand + striking hand.

Resonant percussion sound

a low-pitched, hollow sound heard when tapping (percussing) a body part that contains mostly air

Hyperresonant percussion sound

an abnormally loud, low-pitched, booming sound heard when tapping the chest wall, caused by an excessive amount of air trapped in the lungs or the pleural space

Tympany percussion sound

a high-pitched, drum-like, and relatively long-duration note heard during physical percussion

Dull percussion sound

a short, quiet, high-pitched thud that indicates dense tissue, fluid, or a solid mass instead of air-filled spaces

Flat percussion sound

a soft, high-pitched, and very short tone that lacks resonance

Auscultation

Sounds from the heart, blood vessels, lungs and abdomen

• Check stethoscope fit and quality.

• Know the diaphragm and bell.

• Eliminate confusing artifact. le. Tubing sounds

• Learn normal sounds before abnormal or extra sounds.

When do we measure vital signs

• First encounter: When you first meet the patient Need a basline

• Orders: According to physician or NP orders 5 mins for 30mns

• Condition changes: When the clinical condition changes

• After a procedure: Follow the relevant protocol

• New medication: After starting a new medication

What influences vital signs?

• Age

• Gender

• Ethnocultural background

• Diurnal rhythm

• Peripheral vascular resistance

• Weight

• Exercise

• Emotions

• Stress

• Physiological factors

  • Cardiac output

  • Circulating blood volume

  • Blood viscosity ex: 0M1/2

  • Vessel-wall elasticity

Temperature routes

Oral: Accurate and convenient; not for unconscious or confused patients

Rectal: When other routes are not practical; less comfortable.

Tympanic: Quick, efficient and non-invasive.

Temporal artery: Infrared emissions; multiple readings are

Pulse rate normal

50-90 beats per min

Pulse rhythm

regular and even?

Pulse force

0	Absent
1+	Weak / thready
2+	Normal
3+	Full / bounding

How to determine pulse?

• Locate the pulse: Use the pads of your first three fingers. Feel on the flexor aspect of the wrist, laterally along the radius.

• Counting: count for 30 secs if pulse is regular and multiply by 2.

  • if irregular, count for 60 secs

How to count respirations

Count for 30 secs and multiply by 2

count for 60 secs if an abnormality is suspected

Expected pattern of respiration

• relaxed

• regular

• automatic

• silent

What is blood pressure?

The force of blood against the vessle wall

Systolic

Maximum pressure during left ventricular contraction (push blood out to body)

Diastolic

Resting pressure betweeen contractions (in the heart)

Pulse pressure

Systolic-diastolic

Mean arterial pressure

Average pressure driving blood into tissues

Measure blood pressure systematically

• Prepare equipment: Sphygmomanometer, stethoscope and correctly sized cuff.

• Position the patient: Support the arm at heart level.

• Locate the artery: Palpate the brachial artery.

• Estimate inflation pressure: Note when the pulse disappears, then deflate.

• Inflate and deflate: Inflate 20-30 mm Hg above disappearance; deflate slowly.

• Read the sounds: First sound: systolic. Disappearance: diastolic.

Blood pressure techniques

Position: comfortable, relaxed, arm supported at heart level.

Cuff size: Avoid a cuff that is too narrow or too wide.

Inflation: Check inflation and deflation technique. *speed, leaking

Observation: Identify and record the correct sounds.

Pulse oximetry

• A light-based measurement

• The sensor compares light emitted and absorbed by haemoglobin, then displays an SpO2 percentage.

SpO2 normal range

97-98%

measure for 1 min

above 92% for hospitalized patients

Documentation of findings

• FIRST: confirm full name + date of birth against the patient's ID Band, chart etc.

• Temperature: Value + route.

  • Oral, axillary, tympanic or temporal

• Blood pressure: Systolic/diastolic + position + site.

  • Sitting/supine; arm or thigh

• Oxygen saturation: SpO2 + oxygen delivery + flow rate

  • Room air, nasal cannula or mask; L/min

• Heart rate: Rate + rhythm + method

  • Regular/irregular; radial/apical

• Respirations: Rate + pattern

  • Regular, shallow or laboured

• Pain: Score (0-10) + location + characteristics

  • Include relevant non-verbal signs