introduction to physical assessment Flashcards
(67 cards)
assessment is….
A collection of data about an individuals health care
Subjective Data
What the patient TELLS YOU. what you observe
Objective Data
What is ON the patient
Data Base
The chart and everything else we have going on.
An organized assessment is the starting point of every approach to….
Clinical reasoning…learning and experience
bedside, vital signs, an idea of what is going on.
WHY do we do assessments?
- make clinical judgement or diagnosis
- assess a person’s RISK or actual health problems and life processes
- Diagnose higher levels of wellness
- starting point of all models of clinical reasoning
Baseline
first set of data we collect about a patient
we then know if something has changed
First level priority
Emergent, life threatening, and immediate
ex. CODING airway problems, circulation problems
Second Level priority
Next in urgency, requiring attention so as to avoid further deterioration.
ex. mental status changes, acute urinary elimination problems, diabetic who hasn’t had insulin, abnormal lab values, risk of infections,
Third level priority
Important to the patients health but can be addressed after more urgent problems are addressed
ex. lack of knowledge, activity, rest
The assessment process
Nurse
Professional attitude
Established rapport..no trust= no information
Reflection
Repeat what you have heard to encourage more details
Empathy
Show understanding
Facilitation
Encourage patients to say more
Sympathetic approach
Do something in the same order
spend more time listening than talking
use silence to encourage the patient to continue talking
Effective communication: Seeking connection
At the start open- ended questions: this gives the patient free range to tell us what is wrong.
“ What brings you to the office?”
“ Have there been any changes since the last office visit:
Direct Questions
This is after open ended questions. we need to be more specific
“ How long have you had symptoms?”
Where does it hurt?
Leading questions
MOST RISKY
“ That is a horrible tasting medicine isn’t it?”
Verbal Responses: Empathy
Recognizes a feeling and puts it into words
Verbal Responses: Clarfication
Use when person’s words are ambiguous or confusing
ex. “ when you said…what did you mean?”
Verbal Responses: Confrontation
May focus on discrepancy or inconsistency in person’s narrative
ex. someone who says they are depressed but they do not act or look depressed ( SMILING)
Verbal Responses: Interpretation
It links events, makes associations, implies cause, ascribes feelings
Verbal Responses: Explanation
These statements inform the patient
Verbal Responses: Summary
Final review of what person has said, it condenses facts and presents your view of health problems
