Nursing: Assessment & Diagnosis

Nursing Process: Assessment

• Making reliable observations is part of the nursing assessment
• Distinguishing relevant from irrelevant data is essential in nursing
• Differentiating important from unimportant data is a key aspect of assessment
• Validating collected patient data ensures accuracy
• Organizing data is an important step in assessment
• Frameworks help categorize data during assessment
• Recognizing assumptions is crucial during assessment
• Identifying gaps in the data is a key task to complete the assessment

Nursing Process: Diagnosis

• Finding patterns and relationships among cues aids the diagnostic process
• Making inferences is part of the diagnostic reasoning
• Suspending judgment when lacking data ensures an objective diagnosis
• Stating the problem clearly defines the patient's condition
• Examining assumptions helps the accuracy of the diagnosis
• Comparing patterns with norms aids appropriate conclusions
• Identifying contributing factors is essential when diagnosing

Nursing Process: Planning

• Forming accurate generalizations is involved in the planning process
• Transferring knowledge from one situation to another can aid effective planning
• Developing evaluative criteria helps to measure the success of a care plan
• Hypothesizing involves making potential problem assumptions
• Making interdisciplinary connections improves comprehensive care
• Prioritizing client problems is important on creating an effective plan
• Generalizing principles from other sciences strengthens the care plan

Nursing Process: Implementation

• Applying knowledge during interventions is an implementation step
• Testing hypotheses helps improve future care planning

Nursing Process: Evaluation

• Deciding whether hypotheses are correct is part of the evaluation step
• Criterion-based evaluations assess care and promote quality

Patient Positioning for Physical Assessment

• Accurate patient positioning is critical for physical assessments

Patient Positions

• Listed below are the basic patient positions used in physical assessment
• Supine
• Prone
• Sitting
• Dorsal recumbent
• Sims lateral
• Left lateral recumbent
• Knee chest
• Standing
• Lithotomy

The Supine Position

• Clients should lie down with legs together on an examination table/bed
• Place a small pillow under the head to promote comfort
• The head of the bed may be elevated if the client has trouble breathing
• The supine position relaxes abdominal muscles
• Peripheral pulse sites become easily accessible when supine
• Areas which can be assessed: head and neck, chest and lungs, breast and axillae, heart, abdomen, and all extremities

Supine According to Dillon

• Assessment of the anterior chest for respiratory, cardiac, and breast exams can occur in the supine position
• If someone has trouble breathing, using the semi-Fowler's position can help
• A semi-Fowler's position can be used for pulse extremities
• Semi-sitting with knees flexed and supported by pillows

The Prone Position

• The client lies on their abdomen with the head to the side
• This position is used to assess the hip joint
• The back can also be assessed when prone
• Prone position shouldn’t be done: cardiac problems or respiratory system problems

Prone According to Dillon

• Often using this position is difficult for many patients
• Particularly for those with respiratory diseases
• Musculoskeletal system assessment is the main reason you would put a client in in the prone position.

The Sitting Position

• The client sits upright on the side of the examination table
• It can be done on the edge of chairs or beds (home or office setting)
• Areas That can be evaluated sititing: Head and neck, chest and lungs, breasts and axillae, heart, and extremities.
• Sitting permits full expansion of the lungs and symmetry of upper body parts to be symmetrical
• As an alternative, the client can lie down with the head elevated.

Sitting According to Dillon

• Good visualization of the head and neck
• Full lung expansion and respiratory assessments
• Patients with weakness or paralysis may need a different position or help

The Dorsal Recumbent Position

• The patient lay on the examination table
• Have bent knees
• Legs separated
• The feet should be flat
• More comfortable (back or abdominal patients)
• Don't assess the abdomen (muscle contraction)
• Assessed: head and neck, chest and lungs, heart, breast and axillae, and exterimites

Dorsal Recumbent According to Dillon

• Abdomen - Is basically assessing in a supine position with the knees slightly flexed to relax
• If pt has abdominal pain - Flexing knees is more comfortable
• Female Pelvic area - If the patient is unable to assume lithotomy or Sims position
• Older - May have difficulty assuming lithotomy

The Sim's Lateral Position

• The client lies on their right side
• The lower arm is behind
• The upper arm is flexed (shoulder and elbow)
• The lower leg slightly flexed at the knee
• Upper leg flexed at Sharper pull the forward
• Clients may need assistance into this position
• Allows and assesses: Rectal area and Vaginal area

Sim's According to Dillon

• Assesses: Female pelvic and Recital areas
• If you have arthritis this may difficult to assess
• contradicted if the patient has a total hip replacement

The Standing Position

• Normal, resting position and comfortable
• allows assessment: Posture, Balance, Gait, Male genitalia

Standing according to Dillon

• Assess the spine and joints (ROMS)
• Best position for musculoskeletal areas
• If pt is weak, disabled or paralyzed they may need assistace, may not be able to assume
• Uses the assess : neurological/cerebellar and gait

The Lithotomy Position

• Client will Lay and leans and edge of the back
• Hips at the edges of the examination
• Feet supported by stirups
• May need assistance
• An exposed position embarrassment
• Examination of the: Female genetalia, Reproductive tracts, Rectum
• May not be tolerated: Elderly clients
• Keep the client well draped
• Perform the examination as quickly possibe

The Knee-Chest Position

• Kneels on examination table
• Weight off body supported : Chest and knees
• A 90-degree angle formed: body and hips
• Arm place above the head which turns to one side
• Use small pillow
• examine the rectum
• Can be uncomfortable , embarrsasing , limit time and possible
• Cant tolerate the position: Elderly, cardiopulmonary

Knee-Chest according to Dillon

• Best for rectal positions exam
• This position and alternative bending in this area
• can be difficult embarssing for most pts

Diagnostic Testing: Phases

• The phases involved in diagnostic testing.
• Pretest
• Intratest
• Post-test

Diagnostic Testing: Pretest

• Preparing the client is major focus
• Need to know the client
• To know more Biologic, Psychologic, Sociologic, and spiritual
• Determine pregnancy status
• Precautions are necessary: Lead Apron
• and May be postponed

Diagnostic Testing: End of Shift

• What will you do if you're done with the 3-11 shift?

Diagnostic Testing: Pretest Phase

• If one knowing what was ordered (test)
• if know What sample would be needed?
• Does the client need to stop taking medications
• Does the test Require administration a contest media? YES - is it injected or allowed
• How long is the test?
• Does need consent form?
• Gathering equipment and supplies

Diagnostic Testing: Intratest

• Collecting the specimen
• assisting during the test
• Providing emotional or Standard precatuons Technigue
• monitor the patient the procedure
• Correctly label, or physical support

Diagnostic Testing: Post-test

• Nursing caring of client is major focus
• Involving to follow up activities and observations
• Comparing for previous and current test results
• Modifying the nursing Interventions
• as well to Reporting the (Results necessary)

Common Diagnostic Test

• Blood specimens are
• Complete Blood Count
• Arterial Blood Gas
• Blood Chemistry
• Lipid profile
• Metabolic Screening
• Tests for Hypothyroidism
• Other specimens
• Vizualication procedures and technies
• Lumbar Puncture analysis
• Thoracentesis (fluid)
• Glucose monitoring

Tests Involving Blood Specimens

• Blood Tests Provide hematologic And other systems
• Venipuncture Puncture A vein for the Collect a blood to specimen
• Phlebotomist The lab the perform VENIP
• Complete Blood Count one of the most ordered blood test
• Basic screening test
• assessed pt :
  • Inceftion/Inflammation -Anemia
  • Hemolytic disease
  • Hydration levels
• The blood can show:
  • Hermotrict
  • Red blood cell count
• Hemoglobin

Red Blood Test and White Blood Test

• Measures determine the physical characteristics of the red blood
• What they indicate:
  • Hemtolcrit level
  • Red blood Count
  • White blood count
  • Platelet Count
  • Reliculote counts

Hemoglobin Tests

• main intracellular: protein +erythrocytes
• in - contatining
• transport 0xgen Through the BOdy
• Hemoglobon measures total ammount in the body

Hemotrict Tests

• Hematocrit Percentage - Ratio : Red book cells to the blood count
• Male - have higher percentage than female

Red Blood Tests Levels

• HGB AND HCT (H AND H)
• Increase to dehydration in blood
• Decrease - During and Dilated - Hyper volumn
• Related - To the blood cell count

Red Blood Cell Count

• Counts or red cells are made

Complete Blood count

• Can indicate many things like
  • Infection -Hemoglobin -Hemoatrict

While Blood Cell counts

• Amount circulation in the Blood
• Major function Immunity
• If access - indicates Lerkocylosis - is infections
• If De ficent indicates- Leak oprina Marrow disorder

Plalelet

• Major Intalate coagulation process
• Indicates - Thrombocytogemia Defriit
  • Indicates - Thrombocytopemia

Reticyote counts

• Evaluate cythyrypoises
• Spend only 1 day
• Immature enjthrocytes

###Arterial Blood Gases

• Proviedes PH Partial pressure - carbon oxygen with Excess deficits radial
• Sites brachial or femoral

Diagnostic tests glucose

• Glycosylated The hemoglobin
• Determines for blood sugar control _The Pasts 3 months /90 days and 409 50%

Metabolic testing phenylketonuria

• Phenylketonuria: and inhearted disorder amino acids metabolism
• The Elivated - The phenyialauine , Phenyiupric Acids

Metabolism and Phenyketunuria

• Evalulated - Levels causes one damage/ mentality
• ideal to best - at 2 day of old
• Guthiire test Below : Below 2mm day per 7 Below - 121 umio

Diagnostic Thyroid

• Thyroid Isms - Hypothyroidism . Radioactive Iodine - Uptake study / imaging

Blood Test function thyroid to function

• Iodine given 120 Test: then 12 hours

Thyroid Stimulating Hormones

• diagnose hypothyroidism
• Between and secondary
• Response to therapy
• Functions tests TSH and the totol Thyroxine Adults are (0-4 60/20) /T and the totol

Stool specim

• Speciments the assessor for processes the : The occult, diets, the products and sections and over the parasitites and

During collection testing the for the stool the the specimens

• determine For the reaction for to the collection (amount) and - Is for the correct method for collecting and handing/need of and For preserved? Sent too and for immediately?)
• Save to stool and and the and specimens (Too and four of and repeative tosting}

For Instructions for specimen collection

-Defecate : for clean and for bedpan or for bedside for commode

• Do and for not contaminate :as to much. (wine/for memstrual and discharges)
• Do,not for place: toileth,the fissure- and for bedpan and ather discharged , ( Paper Contents - could affect laboratory results)

Urine and and Body Sample

• Clean or Midstream specimens are the Urine colture
• Sterile specimens -Some bateria-may be- introduced, for the of Casing The uries thoughs.
• Catheterization - are higher of
• For urine - Cufure The for is identify Microrgunisim is Canis -The UTries11) •
• Disposabfe The - clean For Cath - Kilts The may BetAvalabile
• Times, for Urine (specimens the for an Variety to festas That