Physical Assessment J. Carley RN, MSN, MA, CNE Fall, 2009 An Overview
Feb 05, 2016
Physical Assessment
J. Carley RN, MSN, MA, CNEFall, 2009
An Overview
You’re Late !Let’s Start Report….
Rm. 3A: Velma Aguon
76 y.o. P.I.-Am. Female
DX: Hypertensive Crisis
Rm. 4A:Mike Smithe
32 y.o. Afr-Am Male
DX: R/O M.I., HTN
Rm. 5A:Julian Reilly 44 y.o. Cauc.
Male
DX: Pericarditis
Rm. 6A:Ashley Wilkes
26 y.o. Cauc.
Female
DX: Mitral Stenosis
Rm. 7A:Emsley Owens
72 y.o. Afr-Am
Male
DX: CHF
Rm. 8A:Redd Butler
56 y.o Cauc.
DX: Cardiomyopathy,
CHF
Rm. 9A:Faith Hopee
78 y.o. N.A.
Female
DX: A- Fib
Rm. 10A:Frank Arbugast
18 y.o. Afr-Am
Male
DX: Sickle-Cell Cr.
Rm. 11A:Aubrey Embry
38 y.o. J.A.
Female
DX: Endocarditis
Rm. 12A:Yolanda Zahara
55 y.o. M.E. A.
Female
DX: Buerger’s Disease
“New Admission”
RN’s Comment: “Oh, *&%$#!!!”
Nursing ProcessAssessme
nt
Diagnosis
Outcome Identificati
on
Planning
Intervention
mnemonic
“A-D-O-P-I-E”
List of NANDA Nursing Diagnoses
Content and Processof This Course !
Evaluation
The Nursing Process
• A Closer Look
AssessmentCollect Data: √ Review the Clinical Record √ Interview √ Health History √ Physical Examination √ Functional Assessment √ Consultation * Review of the Literature (--Evidence Based Practice)
Diagnosis*Interpret Data: √ Identify clusters / cues √ Make Inferences
* Validate Inferences* Compare clusters of cues w/ definition, defining characteristics* Identify Related Factors* Document the nursing diagnosis
Outcome Identification
--Identify expected outcomes
--INDIVIDUALIZE to the person
--Realistic and MEASURABLE
--Include a TIME FRAME
Planning
--Establish priorities --Develop Outcomes --Set time frames for outcomes --Identify Interventions --Document Plan of Care
“The Nursing Care Plan”
Implementation--Review planned interventions--Schedule & coordinate patient’s care--Collaborate w/ other team members --Supervise implementation by delegation--Counsel patient & family--Involve the patient in their care--Referrals as need for continuity of care--Document care provided
Evaluation
--Refer to the outcomes you established--Evaluate individual’s condition: compare actual outcomes to expected outcomes--Summarize results of the evaluation --If expected outcomes not met, identify reasons--Modify Plan of Care as necessary--Document Evaluation of Outcomes, and changes (if any) in Plan of Care
Nursing Process
Assessment
Diagnosis
Outcome Identificati
on
Planning
Intervention mnemonic
“A-D-O-P-I-E”Evaluatio
n
Subjective DataObjective Data
Objective Data:• Blood Pressure = 142 / 98 mm
Hg• Weight = 158 lbs (= 71.8 kg) • Oral Intake = 2400 mL / 24
hours• Urinary Output = 250 mL / 24
hours• Imbalance Between Oral Intake &
Urinary Output (above)
The Interview
“Yes.”
“Uh Huh.”
“I see…”
The Interview • During the interview, it is a chance for the patient to tell you how he or
she PERCEIVES what is going on—what they THINK (or want you to think) their health state is…
U2: Your Blue Roomhttp://www.youtube.com/watch?v=xS4hJabqRc4
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Learning Games
Part 2:Interviewing & Documentation
The Nursing Interview
“The Nursing Process…”
• Mnemonic: “ADOPIE” = “The Nursing Process”
Assessment
Diagnosis
PlanningImplementation
Evaluation
OutcomeIdentification
Establish Rapport
• Get organized• Do not rely on memory• Plan enough time• Ensure privacy• Get focused• Be calm, confident, warm, and
helpful
Begin the Interview
• Give your name and position
• Verify the client’s name
• Briefly explain your purpose
How to listen• Be an empathetic listener• Use short supplementary phrases• Listen for feelings as well as words• Let the person know when you see body
language that conflicts with what they say
• Be patient if the patient has a memory block
• Avoid the impulse to interrupt• Allow for pauses
How to ask Questions
• Ask about the main problem first = chief complaint
• Focus your questions to gain specific information about the signs and symptoms
• Don’t lead the witness• Restate the other person’s words to
clarify• Use open-ended questions• Avoid closed –ended, yes or no questions
How to terminate the interview• If the session has been long, give
a warning• As the person to summarize their
primary concerns• Ask if there are other areas to be
discussed• Offer yourself as a resource• Explain routines and provide
information about who does what• End on a positive note
Charting & Documentation • If it isn’t written, then it wasn’t
done• Chart at the time it occurs – if
possible• Follow facility guidelines• Is the information clear and
logical?• Is it true?• Is it non - judgmental?• Record all abnormals and normals
Charting guidelines
• Be precise• Stick to the facts• Sign your name after each entry• SOAP format – focuses on specific
problems• AIR, DAR, PIE, DIE formats – focus
on nursing interventions and client response
• Prioritize the client problems
Part Two: Complete Health History
• Biographical Data• Reasons for Seeking Health Care• History of Present Health Concern• Past Health History• Family Health History
Lifestyle and Health Practices Profile
• Description of Typical Day• Nutrition and Weight Management• Activity Level and Exercise• Sleep and Rest• Medication and Substance Use• Self-Concept • Self-Care Responsibilities
Activity IntoleranceActivity Intolerance, Risk forAirway Clearance, IneffectiveAnxietyAnxiety, DeathAspiration, Risk forAttachment, Parent/Infant/Child, Risk for ImpairedAutonomic DysreflexiaAutonomic Dysreflexia, Risk for
Blood Glucose, Risk for UnstableBody Image, DisturbedBody Temperature: Imbalanced, Risk forBowel IncontinenceBreastfeeding, EffectiveBreastfeeding, IneffectiveBreastfeeding, InterruptedBreathing Pattern, Ineffective
NANDA Nursing Diagnosis List
Cardiac Output, DecreasedCaregiver Role StrainCaregiver Role Strain, Risk forComfort, Readiness for EnhancedCommunication: Impaired, VerbalCommunication, Readiness for EnhancedConfusion, AcuteConfusion, Acute, Risk forConfusion, ChronicConstipationConstipation, PerceivedConstipation, Risk forContaminationContamination, Risk forCoping: Community, IneffectiveCoping: Community, Readiness for EnhancedCoping, DefensiveCoping: Family, CompromisedCoping: Family, DisabledCoping: Family, Readiness for EnhancedCoping (Individual), Readiness for EnhancedCoping, IneffectiveDecisional Conflict
Decision Making, Readiness for EnhancedDenial, IneffectiveDentition, ImpairedDevelopment: Delayed, Risk forDiarrheaDisuse Syndrome, Risk forDiversional Activity, DeficientEnergy Field, DisturbedEnvironmental Interpretation Syndrome, ImpairedFailure to Thrive, AdultFalls, Risk forFamily Processes, Dysfunctional: AlcoholismFamily Processes, InterruptedFamily Processes, Readiness for EnhancedFatigueFearFluid Balance, Readiness for EnhancedFluid Volume, DeficientFluid Volume, Deficient, Risk forFluid Volume, ExcessFluid Volume, Imbalanced, Risk for
Gas Exchange, ImpairedGrievingGrieving, ComplicatedGrieving, Risk for ComplicatedGrowth, Disproportionate, Risk forGrowth and Development, Delayed
Health Behavior, Risk-ProneHealth Maintenance, IneffectiveHealth-Seeking Behaviors (Specify)Home Maintenance, ImpairedHope, Readiness for EnhancedHopelessnessHuman Dignity, Risk for CompromisedHyperthermiaHypothermiaImmunization Status, Readiness for Enhanced
Infant Behavior, Disorganizednfant Behavior: Disorganized, Risk forInfant Behavior: Organized, Readiness for EnhancedInfant Feeding Pattern, IneffectiveInfection, Risk forInjury, Risk forInsomniaIntracranial Adaptive Capacity, Decreased
Knowledge, Deficient (Specify)Knowledge (Specify), Readiness for Enhanced
Latex Allergy ResponseLatex Allergy Response, Risk forLiver Function, Impaired, Risk forLoneliness, Risk for
Memory, ImpairedMobility: Bed, ImpairedMobility: Physical, ImpairedMobility: Wheelchair, Impaired Moral Distress
NauseaNeurovascular Dysfunction: Peripheral, Risk forNoncompliance (Specify)Nutrition, Imbalanced: Less than Body RequirementsNutrition, Imbalanced: More than Body RequirementsNutrition, Imbalanced: More than Body Requirements, Risk forNutrition, Readiness for Enhanced
Oral Mucous Membrane, Impaired
Pain, AcutePain, ChronicParenting, ImpairedParenting, Readiness for EnhancedParenting, Risk for ImpairedPerioperative Positioning Injury, Risk forPersonal Identity, DisturbedPoisoning, Risk forPost-Trauma SyndromePost-Trauma Syndrome, Risk forPower, Readiness for EnhancedPowerlessnessPowerlessness, Risk forProtection, Ineffective
Rape-Trauma SyndromeRape-Trauma Syndrome: Compound ReactionRape-Trauma Syndrome: Silent Reaction
Religiosity, ImpairedReligiosity, Readiness for EnhancedReligiosity, Risk for ImpairedRelocation Stress SyndromeRelocation Stress Syndrome, Risk forRole Conflict, ParentalRole Performance, Ineffective
Sedentary LifestyleSelf-Care, Readiness for EnhancedSelf-Care Deficit: Bathing/HygieneSelf-Care Deficit: Dressing/GroomingSelf-Care Deficit: Feeding Self-Care Deficit: ToiletingSelf-Concept, Readiness for EnhancedSelf-Esteem, Chronic LowSelf-Esteem, Situational LowSelf-Esteem, Risk for Situational LowSelf-MutilationSelf-Mutilation, Risk for
Sensory Perception, Disturbed (Specify: Auditory,Gustatory, Kinesthetic, Olfactory Tactile,Visual)
Sexual DysfunctionSexuality Pattern, IneffectiveSkin Integrity, ImpairedSkin Integrity, Risk for ImpairedSleep DeprivationSleep, Readiness for EnhancedSocial Interaction, ImpairedSocial IsolationSorrow, ChronicSpiritual DistressSpiritual Distress, Risk forSpiritual Well-Being, Readiness for EnhancedSpontaneous Ventilation, ImpairedStress, OverloadSudden Infant Death Syndrome, Risk forSuffocation, Risk for
Suicide, Risk forSurgical Recovery, DelayedSwallowing, Impaired
Therapeutic Regimen Management: Community,IneffectiveTherapeutic Regimen Management, EffectiveTherapeutic Regimen Management: Family,IneffectiveTherapeutic Regimen Management, IneffectiveTherapeutic Regimen Management, Readiness for EnhancedThermoregulation, IneffectiveThought Processes, DisturbedTissue Integrity, Impaired
Tissue Perfusion, Ineffective (Specify: Cerebral,Cardiopulmonary, Gastrointestinal, Renal)
Tissue Perfusion, Ineffective, PeripheralTransfer Ability, ImpairedTrauma, Risk for
Unilateral NeglectUrinary Elimination, ImpairedUrinary Elimination, Readiness for EnhancedUrinary Incontinence, FunctionalUrinary Incontinence, OverflowUrinary Incontinence, ReflexUrinary Incontinence, StressUrinary Incontinence, TotalUrinary Incontinence, UrgeUrinary Incontinence, Risk for Urge Urinary Retention
Ventilatory Weaning Response, DysfunctionalViolence: Other-Directed, Risk forViolence: Self-Directed, Risk for
Walking, ImpairedWandering
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