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n t e s m es s As A L I C Y S PH  My parents I need Why are !will to study you RESPI...

n t e s m es s As A L I C Y S PH  My parents I need Why are !will to study you RESPI ?here ,Actually I do not.know Schedule 8:00 – 8:05 Introduction 8:05 – 8:10 Pre Test 8:10 – 9:30 Lecture 1 9:30 – 9:45 Break 9:45 – 11:15 Lecture 2 11:15 – 11:30 Post Test 11:30 – 12:00 Pre-Test/Post-Test Rationale  n t e s m es s As A L I C Y S PH  Assessment process: Is a systematic method by which we plan and provide care for patients. This involves a problem-solving approach that enables us to identify patient problems and potential at-risk needs (problems) and to plan, deliver, and evaluate care in an orderly, scientific manner.  Evaluation Assessment Implementation Diagnosis Planning Assessment  Assessment Is the systematic and continuous: collection Organization Validation documentation of data  The Process Assessment Documenting Collect dataOrganize dataValidate data data  The Process Gathers information to identify the health status of the patient. Assessments are made initially and continuously throughout patient care. The remaining phases of the process depend on the validity and completeness of the initial data collection.  Purposes of assessment To establish Database: all the information about a patient It includes: health history physical examination the physician's history results of laboratory and diagnostic tests  PURPOSE To validate a diagnosis To provide basis for effective care. It helps in effective decision making Basis for accurate diagnosis It promote holistic care To provide effective and innovative care To collecting data for research To evaluation of care Types of Assessment Assessment Initial Focus Time-lapsed Emergency Assessment Assessment Assessment Assessment Initial comprehensive assessment An initial assessment, also called an admission assessment, is performed when the client enters a health care from a health care agency. The purposes are to evaluate the client’s health status, to identify functional health patterns that are problematic, and to provide an in-depth, comprehensive database, which is critical for evaluating changes in the client’s health status in subsequent assessments.  Problem-focused assessment A problem focus assessment collects data about a problem that has already been identified. This type of assessment has a narrower scope and a shorter time frame than the initial assessment. In focus assessments, you will determine whether the problems still exists and whether the status of the problem has changed (i.e. improved, worsened, or resolved). This assessment also includes the appraisal of any new, overlooked, or misdiagnosed problems. In intensive care units, may perform focus assessment every few minute.  Emergency assessment Emergency assessment takes place in life-threatening situations in which the preservation of life is the top priority. Time is of the essence rapid identification of and intervention for the client’s health problems. Often the client’s difficulties involve airway, breathing and circulatory problems (the ABCs). Abrupt changes in self-concept (suicidal thoughts) or roles or relationships (social conflict leading to violent acts) can also initiate an emergency. Emergency assessment focuses on few essential health patterns and is not comprehensive. Time-lapsed assessment or Ongoing assessment Time lapsed reassessment, another type of assessment, takes place after the initial assessment to evaluate any changes in the clients functional health. Perform time-lapsed reassessment when substantial periods of time have elapsed between assessments (e.g., periodic output patient clinic visits, home health visits, health and development screenings)  Assumption in communication communication is a basic clinical skill communication is a series of learned skills or, a set of procedures for improving outcomes of care communication is a learned skill rather than a personality trait anyone who wants to learn can students perceive that effective communication is simply problem solving experience alone can be a poor teacher knowledge of skills does not directly translate into performance Can. J. Neurol. Sci. 2002; 29: Suppl. 2 – S23-S29 Principle that characterize effective communication Ensures an interaction rather than a direct transmission process Reduces unnecessary uncertainty Requires planning and thinking in terms of outcomes Demonstrates dynamism Follows the helical model Can. J. Neurol. Sci. 2002; 29: Suppl. 2 – S23-S29 GoalS of medical communication Promoting collaboration and partnership Ensuring increased Accuracy Efficiency Supportiveness Enhancing patient and physician Improving health outcomes Can. J. Neurol. Sci. 2002; 29: Suppl. 2 – S23-S29 If you can't find time to do it right, how will you find time to do it over? Categories of communication skills Content skills– what AHW say the substance of the questions you ask and the answers you receive, the information you give, the differential diagnosis list, the medical knowledge base you work from Process skills – how AHW say it how you ask questions, how well you listen, how you set up explanation and planning with the patient, how you structure your interaction and make that structure visible to the patient through signposting or transitions, how you build relationships with patients Perceptual skills – what you are thinking and feeling awareness of your own decision making and other thought processes, awareness of and response to your own attitudes and emotions during an interview, whether you like or dislike the patient, your biases and prejudices, noise or discomfort that distracts you from attending to the patient Can. J. Neurol. Sci. 2002; 29: Suppl. 2 – S23-S29 Approaches to communication Shot-put approach the well-conceived, well-delivered message Frisbee approach interaction, feedback, relationship, confirmation, common ground Can. J. Neurol. Sci. 2002; 29: Suppl. 2 – S23-S29 Ten bad habits Dismissing the subject matter as uninteresting Feigning attention Avoiding difficult material Allowing distraction Finding fault with the speaker Listening only for details or facts Becoming overstimulated by something a speaker says Allowing emotion-laden words to arouse personal antagonism Taking notes miscommunication Techniques to sharpen your skills Reflective feedback ask questions, make statements give visual cues that indicate whether you do or do not understand and/or agree Silence remain physically and mentally silent to focus on what is being said Listening with your eyes stay attuned to what the speaker is saying through his or her body positioning, eye movement and contact, physical contact and other body language Positioning lean forward slightly and look at the patient while he or she speaks Improving verbal and non-verbal communication Tempo of speech and tone of voice to ensure that the patient understands, you speak slowly and clearly Pause for digestion and feedback when your message is complex. pause frequently even if you do not sense confusion in the listener; Repeatedly invite questions. To ensure understanding, ask the patient to repeat what they have just been told. Repetition to improve retention, summarize the important points of your message at the end of the consultation or examination Request written questions encourage your patient to write down their questions and bring a list on their next visit Body language maintain eye contact with patients to hold their attention; Patient’s facial expressions and frequent nods will indicate how effectively you are getting the message across. A reassuring smile, a comforting touch and a confident and caring attitude are indispensable Structure and Sequence of Effective Communication Ope Ope gathering data, establishing a nn therapeutic rapport Prepa Gath Gath and educating the Prepa patient re er er re Fundamental Fundamental skills skillsto to maintain during maintain during Elicit Elicitand and the theentire Clos entire understand understandthe the Clos interview interview patient ee I. Use relationship patient’s ’s building skills perspective perspective a. Be organized and logical II. Manage flow b. Manage time effectively in the interview Communicate Communicate Negotiate Negotiateand and agree on plan during duringthe the agree on plan Patient exam exam Patient educati educati NYU School of Medicine on Structure and Sequence of Effective Communication Ope Ope gathering data, establishing a nn therapeutic rapport Prepa Gath Gath and educating the Prepa patient a. Review the patient's chart er re the patient's chart er re a. Review and other data Fundamental and other data Fundamental b. Assess and prepare the b. Assess and prepare skills the b. Assess andto skills prepare to the physical maintain physical maintain environment during environment during Elicit Elicitand and the I. Optimize entire thecomfort entireand Clos I. Optimize comfort and understand understandthe the Clos interview privacy interview privacy patient ee II. Minimize interruptions II. Minimize relationship I. Use and interruptions and distractions patient’s ’s building skills distractions perspective perspective c. Assess II. Manage ones ownflow personal c. Assess ones own personal issues, values, biases, and issues, values, biases, and assumptions going into the assumptions going into the.encounter Communicate Communicate Negotiate and Negotiate and.encounter agree during duringthe the agreeon onplan plan Patient exam exam Patient educati educati NYU School of Medicine on Structure and Sequence of Effective Communication Ope Ope gathering data, establishing a nn therapeutic rapport Prepa Prepa a. Greet and Welcome the and educating the patient re a. Greet and Welcome the re patient patient and family member and family member Fundamental present Fundamental present skills skillsto b. Introduce yourself to b. Introduce maintain yourself during c. Explain maintain role and orient during c. Explain the role and orient entire patient tothe the flow of the visit to theentire patient interview flow of the visit d. Indicateinterview time available and d. Indicate time available and I. other Useother constraints relationship constraints e. Identify and minimize building barriers skills e. Identify and minimize barriers to communication II.toManage flow communication f. Adjust your language and f. Adjust your language and vocabulary to that of the patient vocabulary to that of the patient g. Accommodate patient g. Accommodate patient comfort and privacy comfort and privacy NYU School of Medicine  Structure and Sequence of Effective Communication Ope Ope gathering data, establishing a nn therapeutic rapport Prepa Gath Gath and educating the Prepa patient I. Survey Patient's Reason for theer re re a. Start with er Visit I. Survey Patient's Reason for the Fundamental Visit open-ended questions Fundamental a. Start with open-ended questions skills skillsto b. Invite patient to tell the story chronologically to b. Invite patient to tell thedon't ("Why story chronologically youmaintain start from theduring beginning of your illness") ("Why don't youmaintain start the from theduring entirebeginning of your illness") c. Allow the patient to the talk with minimal interruptions. entire c. Allow the patient the entire to talk with minimal interruptions. d. Actively listen. Encourage completioninterview of the statement of all of patient's concerns through interview d. Actively listen. Encourage completion of the statement of all of patient's concerns through verbal and nonverbal encouragementI. Use verbal and nonverbal encouragement ( ("tell "tellmememore", relationshipmore","anything "anythingelse?", else?",lean lean forward building )) skills forward e. Summarize what you heard. CheckII. forManage flow Invite more ("Anything more?") understanding. e. Summarize what you heard. Check for understanding. Invite more ("Anything more?") II. Determine the Patient's Chief Concern II. Determine the Patient's Chief Concern a. Ask close-ended questions that are non-leading and one at a time a. Ask close-ended questions that are non-leading and one at a time b. Define the concern completely b. Define the concern completely III. Complete the Patient's Medical Database III. Complete the Patient's Medical Database a. Obtain past medical and family history a. Obtain past medical and family history NYU School of Medicine b. Elicit pertinent psychosocial data b. Elicit pertinent psychosocial data Sexual History greet the patient warmly the patient should be helped to be made as relaxed as possible.. look for physical signs of nervousness and embarrassment such as a flushed neck or nervous hand movements,. don't ask any patient questions, especially personal ones, with them lying on a couch and you looming over them. do not be judgmental about a patient’s sex life  Structure and Sequence of Effective Communication Ope Ope gathering data, establishing a nn therapeutic rapport Prepa Gath Gath and educating the Prepa patient re er er re Fundamental a. Ask the patient's idea about illness or Fundamental a. Ask the patient's idea about illness skills skillsto or problem to problemmaintain maintainfor b. Ask what patient's expectations during during the Elicit Elicitand and b. Ask what patient's expectations the entirethe the for entire visit are visit are interview understand understandthe the c. Explore beliefs, concerns andinterview expectations patient c. Explore beliefs, concerns andrelationship I. Use expectations patient’s ’s building skills d. Ask about family, community, and perspective perspective d. Ask about family, community, II. Manage and flow religious or spiritual beliefs and values religious or spiritual beliefs and values e. Acknowledge and respond to patient's e. Acknowledge and respond to patient's concerns, and non verbal cues concerns, and non verbal cues f. Acknowledge frustrations / challenges / f. Acknowledge frustrations / challenges / progress ( wait time. Uncertainty ) progress ( wait time. Uncertainty ) NYU School of Medicine Structure and Sequence of Effective Communication Ope Ope gathering data, establishing a nn therapeutic rapport Prepa Gath Gath and educating the Prepa patient re er er re Fundamental a. Prepare patient Fundamental a. Prepare skills patient to b. Comment skillson aspects to and b. Comment findings of maintain maintain the on aspects during during physical and exam Elicit Elicitand and findings ofthe theentire physical exam the or procedure or procedure entire as interview it is as it is understand understandthe the interview performed performed I. Use c. Listen forrelationship previously patient patient’s ’s c. Listen for previously building skills perspective unexpressed data about the unexpressed II. Managedata about flow the perspective patient's illness or concerns patient's illness or concerns Communicate Communicate during duringthe the exam exam NYU School of Medicine  Structure and Sequence of Effective Communication Ope Ope gathering data, establishing a nn therapeutic rapport Prepa Gath Gath and educating the Prepa patient re er er re Fundamental a. Use Ask-Tell-Ask approach to giving information Fundamental a. Use Ask-Tell-Ask approach to giving information skills to meaningfully - Ask about knowledge, feelings,skillsemotions, to meaningfully - Ask about knowledge, feelings,during maintain reactions, beliefs and expectation - maintain emotions, Tell the information during Elicit Elicitand and reactions, beliefs and expectation - Tell the the information entire clearly and concisely, in small chunks,theavoid "doctor understand clearly and concisely, in small chunks, babble" entire avoid interview interview "doctor understandthe the babble" b. Use language patient canI. understand b. Use language patient can Use relationship understand patient patient’s ’s c. Use relevant information to enhance understanding building c. Use relevant information to enhance skills understanding d. Use aids to enhance understanding (diagrams, models, perspective perspective d. Use aids to enhance understanding II. (diagrams, Manage flow models, printed material, community resources ) printed material, community resources ) e. Encourage questions e. Encourage questions Communicate Communicate during duringthe the Patient exam exam Patient educati educati NYU School of Medicine on  Structure and Sequence of Effective Communication Ope Ope gathering data, establishing a nn therapeutic rapport Prepa Gath Gath and educating the Prepa patient re er er re Fundamental Fundamental a. Encourage shared decision making toskills to the extend skills to the a. Encourage shared decision making to the extend maintain during patient desires maintain during the Elicit Elicitand and patient desires the entire b. Survey problems and delineate options b. Survey problems and delineate c. Elicit patient's understanding, concerns, the entire options interview and preferences understand understandthe the interview c. Elicit patient's understanding, concerns, and preferences d. Arrive at mutually acceptable I. Use d. Arrive at mutually acceptable solution relationship solution patient patient’s ’s e. Check patient's willingness and ability to followskills the plan e. Check patient's willingness and abilitybuilding to follow f. Identify and enlist resources and supports the plan perspective perspective II.and f. Identify and enlist resources Manage supportsflow Communicate Communicate Negotiate Negotiateand and agree on plan during duringthe the agree on plan Patient exam exam Patient educati educati NYU School of Medicine on Structure and Sequence of Effective Communication Ope Ope gathering data, establishing a nn therapeutic rapport Prepa Gath Gath and educating the Prepa patient re er er re b. Inquire a. Signal closure a. Signal closure Fundamental about any other Fundamental b. Inquire about skills to any other issues or concerns skills to c. Allow issues or concerns maintain during opportunity maintain for final during Elicit Elicitand and c. Allow theopportunity entire for final disclosures understand Clos Clos the entire disclosures interview d. Summarize and verify interview understandthe the d. Summarize and verify assessment and plan patient patient’s ’s ee I. e. Clarify Use relationship assessment and plan future expectations building skills e. Clarify future expectations perspective f. Assure plan for unexpected II. Manage f. Assure flow plan for unexpected perspective outcome and follow up outcome and follow up g. Thank patient - appropriate g. Thank patient - appropriate parting statement Communicate Communicate Negotiateand parting statement Negotiate and agree during duringthe the agreeon onplan plan Patient exam exam Patient educati educati NYU School of Medicine on  Steps Of Assessment A. Collection of data  Subjective data collection  Objective data collection B. Validation of data C. Organization of data D. Recording/documentation of data  Collection of Data gathering of information about the client includes physical, psychological, emotion, socio-cultural, spiritual factors that may affect client’s health status includes past health history of client (allergies, past surgeries, chronic diseases, use of folk healing methods) includes current/present problems of client (pain, nausea, sleep pattern, religious practices, medication or treatment the client is taking now)  Types of Data When performing an assessment, gather subjective and objective data. Subjective data (symptoms or covert data) are the verbal statements provided by the Patient. Statements about nausea and descriptions of pain and fatigue are examples of subjective data.  Objective Data Objective data (signs or overt data), are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelt, and they are obtained by observation or physical examination. For example: discoloration of the skin  Data Collection Methods 1. Observing: to observe is to gather data by using the senses. 2. Interviewing: an interview is a planned communication or conversation with a purpose. 3. Examining: Performance of a physical examination. The physical examination is often guided by data provided by the patient. A head-to-toe approach is frequently used to provide systematic approach that helps to avoid omitting important data  Assessment Sequencing Head-to-Toe Assessment Body Systems Assessment Test hearing General Cranial nerves General health status Inspect lymph nodes Vital signs and weight Inspect neck veins Nutrional status Chest Mobility and self care Inspect and palpate breast Observe posture Inspect and auscultate lungs Assess gait and balance Auscultate heart Evaluate mobility Activities of daily living Abdomen Inspect, auscultate, palpate four Head face and neck quadrants Evaluate cognition Palpate and percuss liver, stomach, LOC bladder Orientation Bowel elimination Mood Urinary elimination Language and memory Sensory function Test vision Inspect and examine ears Extremities Skin, hair and nails Palpate arterial pulses Inspect scalp, hair & nails Observe capillary refill Evaluate skin turgor Evaluate edema Observe skin lesion Assess joint mobility Assess wounds Measure strength Assess sensory function Genitalia Assess circulation, movement, & Inspect female client sensation Inspect male client Deep tendon reflexes Inspect skin and nails  Body System approacH General presentation of symptoms: Fever, chills, malaise, pain, sleep patterns, fatigability Diet: Appetite, likes and dislikes, restrictions, written dairy of food intake Skin, hair, and nails: rash or eruption, itching, color or texture change, excessive sweating, abnormal nail or hair growth Musculoskeletal: Joint stiffness, pain, restricted motion, swelling, redness, heat, deformity Head and neck: Eyes: visual acuity, blurring, diplopia, photophobia, pain, recent change in vision Ears: Hearing loss, pain, discharge, tinnitus, vertigo Nose: Sense of smell, frequency of colds, obstruction, epistaxis, sinus pain, or postnasal discharge Throat and mouth: Hoarseness or change in voice, frequent sore throat, bleeding o swelling, of gums, recent tooth abscesses or extractions, soreness of tongue or mucosa.  Endocrine and genital reproductive: Thyroid enlargement or tenderness, heat or cold intolerance, unexplained weight change, polyuria, polydipsia, changes in distribution of facial hair; Males: Puberty onset, difficulty with erections, testicular pain, libido, infertility; Females: Menses {onset, regularity, duration and amount}, Dysmenorrhea, last menstrual period, frequency of intercourse, age at menopause, pregnancies {number, miscarriage, abortions} type of delivery, complications, use of contraceptives; breasts {pain, tenderness, discharge, lumps}  Chest and lungs: Pain related to respiration, dyspnea, cyanosis, wheezing, cough, sputum {character, and quantity}, exposure to tuberculosis (TB), last chest X-ray  Heart and blood vessels: Chest pain or distress, precipitating causes, timing and duration, relieving factors, dyspnea, orthopnea, edema, hypertension, exercise tolerance  Gastrointestinal: Appetite, digestion, food intolerance, dysphagia, heartburn, nausea or vomiting, bowel regularity, change in stool color, or contents, constipation or diarrhea, flatulence or hemorrhoids  Genitourinary: Dysuria, flank or suprapubic pain, urgency, frequency, nocturia, hematuria, polyuria, hesitancy, loss in force of stream, edema, sexually transmitted disease  Neurological: Syncope, seizures, weakness or paralysis, abnormalities of sensation or coordination, tremors, loss of memory  Psychiatric: Depression, mood changes, difficulty concentrating nervousness, tension, suicidal thoughts, irritability.  Pediatrics: along with systemic approach in case of pediatrics, measure anthropometric measurement and neuromuscular assessment. Assessment techniques Inspection Palpation Percussion Auscultation  Assessment techniques - Inspection Close and careful visualization of the person as a whole and of each body system Ensure good lighting Perform at every encounter with your client  Assessment techniques Palpation Temperature, Texture, Palpation Techniques Moisture Organ size and location  Light Rigidity or spasticity  Deep Crepitation & Vibration Position & Size Presence of lumps or masses Tenderness, or pain  Assessment techniques Percussion assess underlying structures for location, size, density of underlying tissue. Direct Indirect Blunt percussion  Percussion Sounds Resonance: A hollow sound. Hyper resonance: A booming sound. Tympany: A musical sound or drum sound like that produced by the stomach. Dullness: Thud sound produced by dense structures such as the liver, and enlarged spleen, or a full bladder. Flatness: An extremely dull sound like that produced by very dense structures such as muscle or bone.  Percussion sounds Example of Quality Length Pitch Intensity Sound origin Normal lung Hollow Long Low Loud Resonance (heard over part air and part solid Lung with Booming Long Low Very Hyper-resonance emphysema loud (heard over mostly air Puffed-out Drum like Moderate High Loud Tympany (heard cheek, gastric over air) bubble Diaphragm, Thud like Moderate Medium Medium Dullness (heard pleural over more solid effusion tissue Muscle, Flat short High Soft Flatness (heard Bone, Thigh over very dense tissue  Assessment techniques Auscultation Listening to sounds produced by the body Instrument: stethoscope (to skin)  Diaphragm –high pitched sounds Heart Lungs Abdomen  Bell – low pitched sounds Blood vessels  Assessment techniques - Setting Environment & Technique Equipment General survey Head to toe or systems approach Minimize exposure Areas to assess first – unaffected areas, external before internal parts  Physical Health Exam-General Survey Appearance  Age, skin color, facial features  Body Structure - Stature, nutrition, posture, position, symmetry  Mobility - Gait, ROM Behavior  Facial expression, mood/affect, speech, dress, hygiene Cognition  Level of Consciousness and Orientation (x4) Include any signs of distress- facial grimacing, breathing problems  Complete Health History Biographical data Reason for Seeking Care History of Present Illness Past Health Accidents and Injuries Hospitalizations and Operations Family History Review of Systems Functional Assessment ( Activities of Daily Living) Perception of Health  Sources of Data Data can be obtained from primary or secondary sources. The primary source of data is the patient. In most instances the patient is considered to be the most accurate reporter. The alert and oriented patient can provide information about past illness and surgeries and present signs, symptoms, and lifestyle. When the patient is unable to supply information because of deterioration of mental status, age, or seriousness of illness, secondary sources are used. The Secondary sources of data include family members, significant others, medical records, diagnostic procedures, …. Members of the patient's support system may be able to furnish information about the patient's past health status, current illness, allergies, and current medications. Other health team professionals are also helpful secondary sources (Physicians, other nurses.)  Validating Data The information gathered during the assessment phase must be complete, factual, and accurate. Validation is the act of "double- checking" or verifying data to confirm that it is accurate and factual.  Purposes of Data Validation ensure that data collection is complete ensure that objective and subjective data agree obtain additional data that may have been overlooked avoid jumping to conclusion differentiate cues and inferences  Data Requiring Validation Not every piece of data you collect must be verified. For example: you would not need to verify or repeat the client’s pulse, temperature, or blood pressure unless certain conditions exist. Conditions that require data to be rechecked and validated include:  Discrepancies or gaps between the subjective and objective data. For example, a male client tells you that he is very happy despite learning that he has terminal cancer.  Data Requiring Validation Discrepancies or gaps between what the client says at one time and then another time. For example, your female patient says she has never had surgery, but later in the interview she mentions that her appendix was removed at a military hospital when she was in the navy  Findings those are very abnormal and inconsistent with other findings. For example, the client has a temperature of 40C. The client is resting comfortably. The client’s skin is warm to touch and not flushed.  Organizing data Thwritten or computerized format that organizes the assessment data systematically. The format may be modified according to the client's physical status.  Body System Model The Body systems model (also called the medical model or review of systems) focuses on the client’s major anatomic systems. The framework allows us to collect data about past and present condition of each organ or body system and to examine thoroughly all body systems for actual and potential problems.  Documenting Data: To complete the assessment phase, record client's data. Accurate documentation is essential and should include all data collected about the client's health status. Data are recorded in a factual manner and not interpreted by AHW.  Purposes of documentation Provides a chronological source of client assessment data and a progressive record of assessment findings that outline the client’s course of care. Ensures that information about the client and family is easily accessible to members of the health care team; provides a vehicle for communication; and prevents fragmentation, repetition, and delays in carrying out the plan of care. Establishes a basis for screening or validation proposed diagnoses. Acts as a source of information to help diagnose new problems.  Purposes of documentation Offers a basis for determining the educational needs of the client, family, and significant others. Provides a basis for determining eligibility for care and reimbursement. Careful recording of data can support financial reimbursement or gain additional reimbursement for transitional or skilled care needed by the client. Constitutes a permanent legal record of the care that was or was not given to the client. Provides access to significant epidemiologic data for future investigations and research and educational endeavors.  Guidelines for documentation Document legibly or print neatly in unerasable ink Use correct grammar and spelling Avoid wordiness that creates redundancy Use phrases instead of sentences to record data Record data findings, not how they were obtained Write entries objectively without making premature judgments or diagnosis  Guidelines for documentation Record the client’s understanding and perception of problems Avoid recording the word “normal” for normal findings Record complete information and details for all client symptoms or experiences Include additional assessment content when applicable Support objective data with specific observations obtained during the physical examination  Assessment Assessment is the first stage of the process in which one should carry out a complete and holistic assessment of every patient's needs, regardless of the reason for the encounter. The purpose of this stage is to identify the patient’s problems. These problems are expressed as either actual or potential. For example, a patient who has been rendered immobile by a road traffic accident may be assessed as having the "potential for impaired skin integrity related to immobility".  Components of aN assessment Biographic data – name, address, age, sex, martial status, occupation, religion. Reason for visit/Chief complaint – primary reason why client seek consultation or hospitalization. History of present Illness – includes: usual health status, chronological story, family history, disability assessment. Past Health History – includes all previous immunizations, experiences with illness. Family History – reveals risk factors for certain disease diseases (Diabetes, hypertension, cancer, mental illness).  Components of aN assessment Review of systems – review of all health problems by body systems Lifestyle – include personal habits, diets, sleep or rest patterns, activities of daily living, recreation or hobbies. Social data – include family relationships, ethnic and educational background, economic status, home and neighborhood conditions. Psychological data – information about the client’s emotional state. Pattern of health care – includes all health care resources: hospitals, clinics, health centers, family doctors.  Documentation of the assessment The assessment is documented in the patient's medical or nursing records, which may be on paper or as part of the electronic medical record which can be accessed by all members of the healthcare team.  Assessment Tools The index of independence in activities of daily living Activities of daily living (ADLs) are "the things we normally do in daily living including any daily activity we perform for self-care (such as feeding ourselves, bathing, dressing, grooming), work, homemaking, and leisure."  Conclusion Assessment is the first and most critical step of the process. Accuracy of assessment data affects all other phases of the medical process. A complete data base of both subjective and objective data allows one to formulate diagnosis, develop client goals, and intervenes to promote heath and prevent disease. In a nutshell… History Focused PE Diagnostics Case, Inno O. Bosya 55 year old male Non-smoker Undocumented fever Productive cough Shortness of breath Cardinal symptoms of respiratory disease…dyspnea Many patients describe their breathing discomfort as “breathlessness,” Many others complain of “tightness,” “choking,” being “unable to take a deep breath,” “suffocating,” being “unable get enough air,” or occasionally even “tiredness.” Decreased activity phenomenon… How many stairs can be climbed before stopping? How far can someone walk on level ground at her or his own pace without stopping? Does talking on the phone, getting dressed, or eating cause dyspnea? Is the patient short of breath at rest? Special types of dyspnea… Paroxysmal nocturnal dyspnea  Episodes of breathlessness that wake persons from a sound sleep,  left ventricular failure  chronic pulmonary diseases because of pooling of secretions Orthopnea  the onset or worsening of dyspnea on assuming the supine position Special types of dyspnea… Instant Orthopnea Platypnea Trepopnea Hyperpnea Cardinal symptoms of respiratory disease…cough Coughing is an essential mechanism that protects the airways from the adverse effects of inhaled noxious substances and defends the lungs by clearing excess secretions. Coughing can be occasional, transient, and unimportant. Cough… acute or chronic, productive or nonproductive, character, time relationships, type and quantity of sputum, associated features. Common causes of cough Irwin RS, Curley FJ, French CL: Chronic cough. The spectrum and frequency of causes, key components of the diagnostic evaluation, and outcome of specific therapy. Am Rev Respir Dis 141:640–647, 1990 Dyspnea and Cough Obstructive lung disease  “Chest tightness”  “Inability to get a deep breath” Congestive heart failure  “Air hunger”  “Sense of suffocation” Tempo and Duration ACUTE CHRONIC Laryngeal COPD Edema Bronchospas IPF m AMI, PE, PTX Key points… Specific triggers? Exertion related? Degree of physical activity? Duration of symptoms? Associated manifestations? Additional symptoms… Wheezing Hemoptysis  bronchitis, lung cancer, tuberculosis, and bronchiectasis  these are also the leading causes of massive hemoptysis (>200 or >600 mL of blood in 24 hours) Chest pain Pedal edema Additional history… Smoking history  “Have you ever smoked?”  “So you are a lifelong nonsmoker?”,  “When did you start?”  “When did you quit?”  “How much did you smoke while you were at it?” Additional history… Environmental tobacco smoke Occupational exposure Travel history  A history of recent travel may help establish the possibility of exposure to infectious diseases that are restricted to specific geographic regions.  SARS 2002  MERS-CoV 2015 Medications  Physical examination Schematic drawing of waveforms in different patterns of breathing. (Adapted from Wilkins RL, Hodgkin J, Lopez B: Lung and.heart sounds online, St. Louis, 2011, Mosby Physical examination Pleural effusion vs Pneumothorax uniform free and easy stroke of the striking finger (plexor) finger being struck (pleximeter) Consolidation vs Pleural effusion Physical examination Adventitious breath sounds  Discontinuous  still often referred to as “rales” in the United States and “crepitations” in Great Britain,  consist of a series of short, explosive, nonmusical sounds that punctuate the underlying breath sound  Continuous  Voice generated  Extrapulmonary  Extrapulmonary manifestations… Pedal edema Jugular venous distention Cyanosis  Clubbing (1) a softening and periungual erythema of the nail beds, (2) an increase of the normal 165-degree angle that the nail makes with its cuticle (3) an enlargement or bulging of the distal phalanx, which may be warm and erythema- tous, and (4) a curvature of the nails themselves Stepwise approach… History Focused PE Diagnostics Summary Taking a careful history and performing a thorough physical examination are essential first steps in formulating a preliminary differential diagnosis of a patient’s complaints. Selected radiographic, laboratory, and other tests are ordered for further and confirmatory evaluation. Because dyspnea, cough with or without hemoptysis, are among the most common reasons for patients to seek consult and because these symptoms may result from serious underlying chest disease, careful questioning and workup is mandatory.