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Introduction Introduction PhysicalPhysical
ExaminationExamination
Health Health AssessmentAssessment
Why do I need to Why do I need to know Physical know Physical Assessment?Assessment?
““What is your What is your reason for reason for coming here coming here today?”today?”
AssessmentAssessment
Collection of data about an Collection of data about an individual’s health state.individual’s health state.
Subjective DataSubjective Data Client historyClient history
Objective DataObjective Data InspectionInspection PercussionPercussion PalpationPalpation AuscultationAuscultation
Data BaseData Base
All the information; obj., All the information; obj., subjective, client’s record, lab, and subjective, client’s record, lab, and test resultstest results
Study and cluster dataStudy and cluster data DiagnosisDiagnosis Purpose of assessment is to make Purpose of assessment is to make
a diagnosis or judgementa diagnosis or judgement
Nursing ProcessNursing Process
ADPIEADPIE AssessmentAssessment DiagnosisDiagnosis (outcome identification)(outcome identification) PlanningPlanning ImplementationImplementation EvaluationEvaluation
Critical ThinkingCritical Thinking
Problem solving – the puzzle – the Problem solving – the puzzle – the big picturebig picture
Processing information – use Processing information – use theory learned, experience, theory learned, experience, intuition, intellectual and manual intuition, intellectual and manual skillsskills
Priority SettingPriority Setting
First level problemsFirst level problems ABC’sABC’s Vital SignsVital Signs
Second LevelSecond Level Mental Status changes (LOC)Mental Status changes (LOC) Acute painAcute pain Acute urinary eliminationAcute urinary elimination Untreated medical problemsUntreated medical problems Abn. Bld. ValuesAbn. Bld. Values Risks of infection, safety, securityRisks of infection, safety, security
Third Level PriorityThird Level Priority Knowledge deficitKnowledge deficit Activity, restActivity, rest CopingCoping
4 Types of Data Base4 Types of Data Base
1.1. Complete ( Total ) Complete ( Total )
2.2. Episodic or Problem CenteredEpisodic or Problem Centered
3.3. Follow – upFollow – up
4.4. EmergencyEmergency
Consideration of:Consideration of:
Developmental StatesDevelopmental States Cultural AssessmentCultural Assessment
Beliefs, values, practicesBeliefs, values, practices
The InterviewThe Interview
““Spend more time listening”Spend more time listening” Open /Closed ended questionsOpen /Closed ended questions InterpreterInterpreter
Family/ professionalFamily/ professional
Communication SkillsCommunication Skills
Collecting information with Collecting information with understandingunderstanding
Verbal/NonverbalVerbal/Nonverbal
Factors that impact on Factors that impact on CommunicationCommunication
InternalInternal Personal attributes – acceptance of Personal attributes – acceptance of
client (Nonjudgemental)client (Nonjudgemental) RespectRespect Empathy Empathy ListeningListening
Factors that impact on Factors that impact on CommunicationCommunication
External FactorsExternal Factors PrivacyPrivacy InterruptionsInterruptions Comfortable environment – temp., Comfortable environment – temp.,
noise, lunch, bloody mess noise, lunch, bloody mess
10 Traps of Inteviewing pg 10 Traps of Inteviewing pg 5757
1.1. False AssuranceFalse Assurance
2.2. Unwanted AdviceUnwanted Advice
3.3. Using AuthorityUsing Authority
4.4. Avoidance language – dead is deadAvoidance language – dead is dead
5.5. Engaging in distance “the Friend” Engaging in distance “the Friend”
6.6. Professional jargonProfessional jargon
7.7. Leading or biased questions; “you Leading or biased questions; “you don’t…?”don’t…?”
8.8. Too much talkingToo much talking
9.9. InterruptingInterrupting
10.10. Why? Why?
Threat of Violence!!!!Threat of Violence!!!!
CPI training CPI training