NCMA 121 Week 1-2 PDF

WEEK 1 DIAGNOSIS and TREATMENT OF HUMAN RESPONSES (Nursing Process, Health Assessment in Nursing Practice, & Nurses Role in Health...

WEEK 1 DIAGNOSIS and TREATMENT OF HUMAN RESPONSES (Nursing Process, Health Assessment in Nursing Practice, & Nurses Role in Health We do not directly manage the disease process (for doctors only) Assessment) WHAT DO NURSES DO? For us nurses Nurses' responsibility -​ constantly observe and collect information from patients -we manage the person towards their response on their illness -​ To make correct nursing judgments For example, We do this regardless of the settings Fever because of infection -hospital, clinic, community, at home -the doctor manage the infection We conduct informal assessments every day -lever is the response of the body towards infection professional nursing assessments you make on a client, family or community -nurses manage the fever -​ which will determine nursing interventions or nursing actions -​ that will directly or indirectly influence the patient's health status NURSING SCOPE AND NURSING STANDARD ON PRACTICE ASSESSMENT STANDARD 1- Registered nurses collect comprehensive data pertinent to the patient's health or situation. (You need to understand The Republic Act. 9173 or the Philippine Let us assess nursing act of 2002 Article VI scope of nursing if you will practice nursing in the Philippines) Mr. Wong, 45 y/o, arrives in the emergency room ➤ Collect data in a systematic and ongoing process What is your assessment based on his facial expression and body gesture? ➤ Involves the patient, family and other health care providers (holistic) because this is a collaborative approach now. When you say patient it is not just the patient itself it What is your assessment based in his conjunctiva? includes the patient's family and even the community of the patient ➤ Priorities data collection activities based on the patient's immediate condition DEFINITION OF NURSING ➤ Uses appropriate evidenced based assessment techniques and instruments in collecting data "The protection, promotion and optimization of health and abilities, prevention of illness ➤Uses analytical models and problem-solving tools and injury. alleviation of suffering through the diagnosis and treatment of human ➤ Synthesises available data, information and knowledge relevant to the situation to responses and advocacy in the care of individuals, families, communities and population" identify patterns and variances (AΝΑ, 2010) ➤Document relevant data in a retrievable format (documentation of data is very crucial, your documentation is a form of communication between you and other healthcare team NOTE: The definition now of nursing is different from before. If you are a nurse you are members. So when you say retrievable format you need to document all of your just caring for the sick people but now we define nursing as someone or method to assessment findings in the nurses chart or the patient's chart. When you say retrievable promote prevent illnesses and injury. According to WHO if restoring the patient back to format other people who are part of the healthcare team should be able to see it.) health is already impossible (already dying and you cannot do anything about it) helping the patient to have a peaceful and comfortable moment before he or she dies is also one STANDARD 2- "The registered nurse analyzed the assessment data to determine the of our responsibilities (assisting to a peaceful death). diagnoses or issue ➤ derives the diagnosis or issue based on assessment data ➤ validates the diagnoses or issue with the client, family and other healthcare providers when possible and appropriate 3. There are basic human needs that must be met. ➤ document diagnoses or issue in a manner that facilitates the determination of expected outcomes and plan 4. When these needs are not met, problems arise that may require intervention by another person until the individual can resume responsibility for themselves. WHAT IS NURSING? 5. Human experience is contextually and culturally defined. -​ When you say nursing is an art, these are abstract forms like you being an advocate for your patient's rights, you giving care, you giving part of yourself It is important for us to understand the culture of your patient to become an effective to your patients. nurse. -​ While nursing as a science is the theoretical part of nursing, these would be 6. Clients have a right to quality health and nursing care delivered with interest, your nursing assessment, nursing interview, your vital sign Saking thorough compassion and competence, with a focus on wellness and prevention. physical examination, you giving medication to your patients, you assisting the doctor in the surgery, and you delivering the baby. Very important especially the word interest, compassion and competence because this is a very demanding and challenging profession and if you're not compassionate enough to Nursing is both a science and art concerned with the holistic approach of a man pursue this profession you will have a difficult time. 1. Physical 7. The therapeutic nurse-client relationship is important in the nursing process. 2. Psychological It is important for you to establish a good rapport so you will have al therapeutic nurse client relationship 3. Sociological EVOLUTION OF NURSE'S ROLE IN HEALTH ASSESSMENT 4. Cultural Late 1800's-1900's nurses relied on their natural since we don't yet have the BP 5. Spiritual apparatus, Stethoscope and thermometer. Client's use the face and body of the patient to observe if there are changes in color, temperature, things like this and they only use their FUNDAMENTAL PHILOSOPHICAL BELIEFS IN NURSING hands to palpate the pube rate and use eyes to observe hydration and nutrition. 1. The client is a human being who has worth and has dignity. Physical assessment is an integral part - since Florence Nightingale continues to develop That's why we care for life, we don't just throw lives away and every human being has the -will continuously develop right to proper healthcare, to maintain its worth and dignity. What are the roles of nurses during the late 1800's and early 1900's? 2. Humans manifest an essential unity of mind/body and spirit. Nurses relied on their natural senses -assessment is based on the nurses natural senses That's why some of your patients, if they are already diagnosed with a terminal illness or cancer, if they can still walk, talk and do their activities of daily living they will still How is the assessment done? continue to tell you that they are healthy because we do have different definitions of The client's face and body is observed (mostly observation) for changes with regard to being healthy or well. I may be physically healthy but have sickness or illnesses. -color However, I am depressed or sad and I cannot do my activities of daily living because I -temperature don't feel like moving even though I am not diagnosed with any diseases. If my state of - muscle strength mind is like that I may not consider myself healthy. -the use of limbs and degrees of nutrition and hydration 1930-1949 This is the start of public health nursing. For case findings, prevention of -Tools that guided the client's progression which nurses are responsible for assessing and communicable disease, routine assessment in four areas. validating Nurse's role already includes. Proliferation of advanced practice nursing -client and home inspection by public health nurses -Those nurses that underwent skills trainings and specialization were used as clinical -case finding nurse specialists in the hospital and community as nurse practitioners -prevention of communicable diseases -routine use of assessment skills WHAT IS THE NURSING PROCESS? 1950-1969 This is the start of your employment health assessment. So before an "Combines the most desirable elements of the art of nursing with the most relevant employee or a person gets hired in a company that person should have a physical elements of systems theory, using the scientific method" - Shore 1988 examination first. -nurses were hired to conduct pre-employment health histories This process incorporates an interactive/interpersonal approach with a problem solving -physical examinations for major companies (new York telephone company in the US) and decision-making process - Peplau 1952 1970-1989 was the start of a thorough physical assessment or nursing process. Dito na -Is a SYSTEMATIC, organized method of planning. and providing quality and nag start ang ADPIE(Assessment, Diagnosis, Planning, Implementation, Evaluation) individualized nursing care. -Nurses develop an active role in the provision of primary health services -Nurses develop an expanded role in conducting health histories. and physical and -It is synonymous with the PROBLEM-SOLVING APPROACH that directs the nurse psychological assessments. and the client to determine the need for nursing care, to plan and implement the care and -Nurses were encouraged to perform in-depth client assessments and on-the-spot evaluate the result diagnostic judgments -nurses were more exposed to more "complicated cases -care was not just limited just (so in the assessment phase you'll know the problem, you gather data for you to be able to limited to "simple" illnesses know what the problem. the patient will come to the hospital because they have a During 1980's problem. There must be a problem and for every problem we should find a solution and Nurses already employ primary care in acute care settings this is how we are going to fund a solution for the problem of the patient through the -each nurse was autonomous in making comprehensive initial assessments nursing process) -from which individualized POC were established -This is until now! IN SHORT THE NURSING PROCESS IS A SYSTEMATIC PROBLEM-SOLVING APPROACH 1900-Present-now nurses are a very important part of the health assessment to the patient -Where diagnosis and treatment are achieved. because we are the one conducting the interview, the vital signs etc. Everything starts -It is a GOSH approach for efficient and effective provision of nursing care. with us so without our assessment we will not be able to do a nursing diagnosis that can help the patient and the doctors will have a difficult time knowing what's the problem of Your nursing process must be GOSH the patient. So it's crucial for us to understand and learn the health assessment G-GOAL ORIENTED Provision of health care from acute settings to the community Proliferation of O-ORGANIZED baccalaureate and graduate education S-SYSTEMATIC H-HUMANISTIC CARE During this time Nurses are already involved in budgeting and restructuring health care provisions Critical pathways and care maps are used What are these? (When you say that you are an effective nurse while taking vital signs your patients temp You should add the rationale there should always be a rationale for every nursing is 39 degree's celsius, so your patient has a fever. You are an efficient nurse because you intervention. were able to assess and check that your patient is actually suffering from fever. ➤ For example your patient has a fever and you wrote in your intervention to provide a Now to become an effective nurse you will do your nursing intervention in order to tepid sponge bath. You should place a rationale why you provide a tepid sponge bath let alleviate the suffering of the patient so that your patient will have a normal body temp. say to make the patient feel comfortable and to decrease the fever of the patient. Next is You will place a cool on his forehead; you will administer medication as per doctor's you administer 500mg if paracetamol as per doctor's order (medication should always be order. We say that after 2hrs of doing this nursing intervention you recheck the patient ordered by the physician and medication administration a dependent nursing intervention and it is now 37.5 so your patient now at least ang temp. So now you can be considered meaning you always need an order from the doctor but when you say independent as an efficient nurse because you were able to help your patient to Improve from one nursing intervention these are your actions that don't need order from physician, you can status to another status.) do it on your own) then you have to put the rationale why you administer the medication. There must be two ways you cannot be effective without being an efficient nurse. PHASE V-EVALUATION ➤ Assessing whether outcome criteria gave been met and revising the plan as necessary. PURPOSE OF NURSING PROCESS ➤ You will assess if your goal has been achieved 1. To identify a client's health status; his Actual/Present and potential/possible health STEP 1-ASSESSMENT problems or needs. Most critical phase of nursing process. Why? 2. To establish a plan of care to meet identified needs Because if data collection is inadequate. inaccurate, incomplete, incorrect nursing 3. To provide nursing interventions to meet those needs. judgement or nursing diagnosis may be make. And if you have incorrect assessment, incorrect nursing diagnosis It will be a domino effect everything will be incorrect. So the 4. To provide an individualized, holistic, effective and efficient nursing care. first one should always be correct so the entire process would be appropriate and adequate for your patient. PHASES OF NURSING PROCESS ➤ Assessment is ongoing and continuous through all phases of the nursing process PHASE I-ASSESSMENT ➤ Assessment is more than just gathering of information about health status, it is ➤ Collecting subjective and objective data (Most critical) analyzing and synthesizing that data, making judgements about the effectiveness of nursing interventions and evaluating client care outcomes. Because actually assessment is PHASE II - DIAGNOSIS done all throughout the phases of nursing process. Assessment is not just done in step 1 ➤ Analyzing subjective and objective data to make a professional nursing judgement you will do assessment in step 3, you will do assessment in evaluation, of course you will (nursing diagnosis, collaborative problem or referral) need to reassess and ask the patient again if the intervention are effective. Interviewing or taking the vital sign of the patient you will not just do these in the assessment phase you PHASE III-PLANNING will do this in the entire nursing process. ➤ Determining outcome criteria and developing a plan FOCUS OF HEALTH ASSESSMENT IN NURSING Now you collected your data, you already know the problem of your patient now you will plan to resolve the problem of your patient The purpose of nursing health assessment is to collect holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional PHASE IV-IMPLEMENTATION clinical judgement. ➤Carrying out of the plan Is the doing phase FRAMEWORK FOR GOAL ASSESSMENT IN NURSING (things you need to know and ask to your patient during the assessment phase) with every 2. ONGOING OR PARTIAL ASSESSMENT hospital there will be interview guide or checklist guide that you will follow in interviewing the patient. An ongoing or partial assessment if the client consist of data collection that occurs after comprehensive data is established. -History of present health concern -Personal health history ➤ Mini overview if the client's body system and holistic health patterns as a follow up -Family history health status - Lifestyle and health practices ➤ Reassessment to detect new problem TYPES OF HEALTH ASSESSMENT Example: You are a nurse working in a general ward and you admitted a patient who came from the ER of course when the patient came from the ER someone already did an 4 basic types of assessment because for example you are an ER nurse your assessment in interview to this patient for baselining. Of course your not gonna repeat all of those the ER will be different from the assessment of the nurses working in the general ward. questions because you already know the problem of the patient, there iss alreadyra reason why the patient is admitted to your area. Example your patient is admitted to your ward Initial comprehensive assessment for lung cancer for sure your patient already have a baseline data coming from somewhere else like clinic, ER, OR. Now you will do your reassessment questioning to Ongoing or partial assessment detect new problem to your patient with lung cancer because it is possible that your patient may have difficulty in breathing, patient can be anxious something like that. That Focused or problem-oriented assessment should be the focus of your assessment. Emergency assessment 3. FOCUSED OR PROBLEM-ORUENTED ASSESSMENT 1. INITUAL COMPREHENSIVE ASSESSMENT It is performed when a comprehensive database exist for a client who comes to the health care agency with a specific problem ➤ Involves collection of subjective data about the client's perception of his or her health if all body oarts or systems, past health history, family history, lifestyle and health ➤ Consist of thorough assessment of a particular client problem and does not cover areas practices. As wall as objective data gathered during step by step physical examination. not related to the problem In short this will be the type of assessment that you do for base line information, so you Example: Patient with pain. Now your questions will be focused in knowing ba out the will ask everything during initial comprehensive assessment kaya nga sya tinawag na pain. ganyan kase you will be asking all the pertinent info demographic data, biographical data and etc. YOU HAVE TO REMEMBER THE MNEMONIC COLDSPA THESE IS FOR ➤ Regardless of who collects the data, a total health assessment (S and O) is needed ASSESSING PAIN. when client first enter the health care facility to provide baseline data for future health status changes. C-CHARACTER - describe how does it feel? Example: A child with suspected dengue hemorrhagic fever goes into the ER and this is O-ONSET when did it begin? When did it start? the first time this patient goes to the hospital so now you need to have your baseline information because you don't know these patient, this hospital don't know this patient so L-LOCATION where is it? Where does it radiate? (nasaan ang pain?) you need to get all the info D-DURATION-how long does it last? (does it reoccur or you always feel the pain) S-SEVERITY how bad is it? (to quantify the level of pain we use pain scale 1-10) P-PATTERN-things to do to lessen the pain or action that you do to aggravate the pain PROCESS OF DATA ANALYSIS A- ASSOCIATED PROBLEM what do you think thenreason from pain or injuiry To arrive at nursing diagnoses, collaborative problem or referral, you must go through the steps of data analysis. This process requires diagnostic reasoning skills, often called 4. EMERGENCY ASSESSMENT critical thinking. The process can be divided into seven major steps: A very rapid assessment performed in life threatening situations (use your common sense 1. Identify abnormal data and strengths and you will not ask questions most of the time if this happens) 2. Cluster the data 3. Draw inferences and identify problems An immediate assessment is needed to provide prompt treatment 4. Propose possible nursing diagnoses 5. Check for defining characteristic of those diagnoses ➤ The major and only concern during this type of assessment is to determine the status 6. Confirm or rule out nursing diagnoses of the client's life sustaining physical functions 7. Document conclusions Example: choking, cardiac arrest, drowning 4 TYPES OF NURSING DIAGNOSES STEPS OF HEALTH ASSESSMENT 1. ACTUAL OR PROBLEM-FOCUSED problem of the patient (ineffective breathing pattern) The assessment phase if nursing has 4 major steps. Indicates that the client is currently experiencing the problem 1. Collection of subjective data Ex Ineffective breathing pattern (diagnostic label in NANDA- always refer to the diagnostic 2. Collection of objective data label) -this reflects an actual problem in the respiratory system A client with a reddened area on 3. Validation of data the R buttocks -the actual ND is impaired skin integrity 4. Document of data 2. RISK risk of something, risk for infection (the patient does not have a problem yet but STEP TWO-NURSING DIAGNOSIS there is a risk that he or she might have this problem) Analysis of data (often called nursing diagnosis) is the second phase of the nursing The client is vulnerable to an actual ND that will most likely occurIn this case process. Analysis of the collected data goes hand in hand with the rationale for The client does not manifest any symptoms or defining characteristics performing a nursing assessment. Ex. Risk for infection-there are still no signs of infection During this phase, you analyze and synthesize data to determine whether the data reveal a nursing concern (nursing diagnosis) a collaborative concern (collaborative problem) or a 3. HEALTH PROMOTION you use this mostly if the patient is ready for discharge, more concern that needs to be referred to another discipline (referral) on health education, instruction so they will continue their recovery even when they are at home A nursing diagnosis is defined by the North American nursing diagnosis association - readiness for enhanced family coping (NANDA) as a "clinical judgement about individuals, family or community responses to -The client may or may not have a problem actual and potential health problems and life processes. -The client now desires to attain a higher level of health -The client wishes to increase his or her well-being -this type of diagnosis indicates an opportunity tto make life greater -to increase the quality of life -to attain the most desired level of function FOCUS OF THE DIAGNOSIS Fluid volume 4. SYNDROME syndrome) known illness(chronic pain syndrome) Nutrition: less than body. requirements Clinical judgments that describe a specific cluster of ND that occur together Gas exchange -group of ND that are similar or is associated Tissue perfusion -cluster of problems or group of problems Injury They have a similar nursing intervention to resolve the situation Ex Etiology It can be actual or risk ND The etiology, or related factors and risk factors, component of a mursing dagnosis lahel identifies one or more probable causes of the health problem, are the conditions involved SND include in the development of the problem, grees direction to the required nursing therapy, and -frail elderly syndrome enables the nurse to individualize the client's care -pain syndrome -post-traumatic syndrome -rape-trauma syndrome Defining Characteristics -sudden infant death syndrome Delining characteristics are the clusters of signs and symptoms that indicate the presence of a particular diagnostic Isbel. In actual nursing diagnoses, the defining characteristics -on ex. --chronic pain syndrome are the identified signs and symptoms of the client. COMPONENTS OF A NURSING DIAGNOSIS HOW TO WRITE A NURSING DIAGNOSTIC PES FORMAT Writing diagnostic statements A nursing diagnous les typically tune components (1) the problem and its deletion (2) the stiology and (3) the defining characteristics ONE-PART if it is about health promotion (readiness for enhanced breastfeeding) 1. PROBLEM pain (acute pain) TWO-PART-If your diagnosis will focused on the risk (risk got infection related to 2. ETIOLOGY - reason of the problem (related to tissue ischemia) compromised host defenses) 3. SIGNS AND SYMPTOMS as evidenced by statement of "I feel severe pain in my chest!" THREE-PART if your nursing diagnosis is problem- focused which we usually do (impaired physical mobility related to decreased muscle control as evidenced by inability PROBLEM AND DEFINITION to control lower extermity) The problem statement, or the diagnostic label, describes the client's health problem or Example: Nursing diagnosis: Acute pain (main prob) related to physical injury agents response for which nursing therapy is given as concisely as possible. A diagnostic label (etiology) as evidenced by trauma during a recreational activity (signs and symptoms) usually has two parts: qualifier and focus of the diagnosis STEP III-PLANNING QUALIFIER "How to manage the problem" Deficient Based on assessment and diagnosis, nurses set measurable and achievable and long-range Imbalance goals Impaired Ineffective Short Term Goal Risk for Long Term Goal S - SPECIFIC -Are the interventions effective and efficient? M-MEASURABLE -Is there a need to revisit the entire nursing process? A - ATTAINABLE R-REALISTIC Let say after 4hrs the pain scale is still 7/10 after all those nursing intervention that you T-TIMEFRAME done the pain scale if the patient got even worse 10/10. your interventions are not efficient enough. You need to revisit your planning and you need to revise your planning ➤ This is the goal planning so you should do your goal for you to be able to help the and do other nursing intervention if your goals are not met. patient feel comfortable. ➤ How you will manage the problem or your goal. It should be based on the assessment and diagnosis. Example from Mr. Wong's case Planning: After 4hrs of nursing intervention patient's pain scale should improve from 7/10 to 4/10 STEP 4-IMPLEMENTATION Putting plan of care into action ➤ Also called nursing care intervention ➤ Involves carrying out your plan to achieve goals and outcomes The doing phase Example: Patient left foot is swollen. You can instruct the patient or do the RICE. Ask the patient to REST the injured foot. IMOBILIZE the left foot and tell your patient to not move it. You will do ice COMPRESS to alleviate the swelling in the area. You will ELEVATE the foot to decrease the swelling of the foot. As per doctor's order you can administer your patient paracetamol 500mg or 900mg IV to alleviate the pain. You can also administer anti- inflammatory medication to decreased in the left foot. Your doctor will also do X-ray in the left foot. ➤ Every nursing intervention that you will document you need to write the rationale why you are doing those interventions. Facilitates X-ray of the left foot to visualize and to check if there are fracture on left foot. Administered anti-inflammatory medications and paracetamol to alleviate swelling and pain. ➤ Always put the rationale beside your nursing implementation STEP 5-EVALUATION ➤ The outcome of the patient after the interventions were rendered. ➤ Is the goal achieved? ➤ Did the plan work? WEEK 2 DATA COLLECTION METHODS (Collection of SD, Collection of OD, Validation of data, Documentation of data) √Observing √Interview ASSESSMENT Is the first and most critical phase of the nursing process. DATA COLLECTION METHODS Assessment is ongoing and continuous throughout all phases of √ Observing the nursing process. - To gather data using the senses Health assessment is: - A conscious, deliberate skill Gathering information about the health status of the client - 2 aspects Analyzing and synthesizing that data Noticing the data Making judgments about the effectiveness of nursing Selecting, organizing and interpreting interventions the data Evaluating client care outcomes The nursing process should be thought of as circular, NOT LINEAR. √Interview - Planned communication or conversation NURSING ASSESSMENT with a purpose TYPES OF DATA - To get or give information - Identify problems of mutual concern Subjective Data - Evaluate change, teach, provide support symptoms or covert data - Provide counselling or therapy apparent only to the person affected Objective Data PREPARING FOR THE ASSESSMENT signs or overt data Review the medical records if available detectable by an observer Know the client's basic biographical data (age, sex, religion, educational level can be measured, tested and occupation Activities of daily living SOURCES OF DATA Client's previous and current health status (patient and family) √ CLIENT Keep an open mind and refrain from premature judgement - Best source of data, subjective data Educate self Reflect on your own feelings √ Support people Obtain and organize materials that you will need for the assessment - Family members, friends and caregivers - Important source of data if the client is young, COLLECTING SUBJECTIVE DATA unconscious or confused Subjective data include: Sensation or symptoms √ Client records Feelings - Information documented by other healthcare Perceptions professionals Desires Preferences SOURCES OF DATA Beliefs √ Health care professionals - verbal reports Ideas √ Literature - journals, reference texts, Values published studies Personal Information Any data that can be elicited and verified only by the client. -are you in pain? -how many years you are working in the plastic industry? COLLECTING SUBJECTIVE DATA -these questions helps us to get basic information about the The nursing interview is a communication process that has two focuses: patient 1. Establishing rapport and a trusting relationship Gathering information on the client's developmental, psychological, physiologic, Laundry list sociocultural and spiritual statuses to identify deviations that can be treated with nursing -provide client with list of words for them to choose when and collaborative interventions or strengths that can be enhance through nurse-client describing symptoms collaboration -helps obtain specific answers -is the pain severe, dull, sharp, mild, cutting, piercing COLLECTING SUBJECTIVE DATA Communication during the interview Rephrasing Nonverbal communication -helps clarify information Appearance Ex. Demeanor -Patient complains of how he/she is really tired, nauseated fo 2 months, he/she is scared Facial Expression that they have a horrible disease Rephrase by Attitude -are you thinking that you have a serious illness? Silence Listening Inferring -may help you elicit more information or verify information COLLECTING SUBJECTIVE DATA Take note! Verbal Communication -do not lead the client to answers that are not true or not exactly or not Open Ended Ex. Closed Ended questions accurate Laundry List -Patient tells you that they have bad pain Rephrasing -ask client where the pain is Inferring -patient place their hand on the right lower quadrant of the abdomen-tell them "it seems Providing Information that you have more pain in the right side of the stomach (use stomach, they know this not abdomen) Open-ended -this will help illicit more accurate data -cannot be answered with yes or no -typically begins with what or how Providing information -explanation or describing is necessary -as questions arise -tell me how you feel? -answer every question as thoroughly as you can -describe your pain? -if you do not know, tell them you will find out -require more than a word answer Take note! -this gives your patient to explain and answer openly -If patient has knowledge of their health status -they participate with their care more Closed-ended -answered with yes or no COLLECTING SUBJECTIVE DATA -answered with simple responses only What to avoid? -typically begins with when or did -when did your headache start?or you may ask this also Non Verbal Communication -how old are you? Excessive or insufficient Eye Contact Distraction and Distance Working phase Standing Longest Phase Verbal Communication Uses verbal / nonverbal Biased or Leading Questions Rushing through the interview Reading the question Elicits the client's comments about -major biographic data COLLECTING OBJECTIVE DATA -reasons for seeking care The examiner directly observes objective data. These data include: -history of present health concern Physical characteristics (Skin color, posture) -past health history Body functions (Heart Rate, respiratory rate) -family history Appearance (Dress and hygiene) -review of body systems for current health problems Behaviors (mood, affect) -lifestyle and health practices Measurements (Blood pressure, temperature, height and weight) -developmental level Result of laboratory testing Listens, observes cues, uses critical thinking skills -to interpret and validate information received from the client This type of data is obtained by general observation and by using the four physical The nurse and client collaborate to identify the client's problems and goals examination techniques: inspection, palpation, percussion, and auscultation. Another source of objective data is the client's medical record.Objective data may also be Summary and Closing Phase observations noted by the family or significant others Summarize, restate or clarify Summarizes information obtained during the working Phases of the Interview phase Pre - Introductory Validates problems and goals with the client Introductory Identifies and discusses possible plans to resolve the Working Phase problem with the client Summary And Closing Phase Makes sure to ask if anything else concerns the client and if there are any further questions Pre -Introductory Phase Review medical record before meeting with the TYPES OF INTERVIEW client √ Directive Interview Take note! - Highly Structured If a medical record is not established - Controlled by the Nurse -rely on interview skills to elicit valid and - Elicits specific information reliable data - Nurse uses directive questions -from the client, family or significant other Directive interviews Introductory Phase Structured with specific questions Explains the purpose of the interview Controlled by the nurse Discusses the types of questions (open, close) that will be asked List of questions are already prepared (directive questions) Explains the reason for taking notes Require less time Assures the client that confidential information will remain confidential Very effective for obtaining factual data (based on facts not on interpretations) Makes sure that the client is comfortable (physically and emotionally) and has PRIVACY Elicits specific information Develop trust and rapport at this point May use open or close-ended questions What is your name? What is your occupation? What is your major health care or concern?Who buys and prepares the food you Leading Questions eat?Where do you eat your meals? Closed questions (Y or N) Directive questions (structured) TYPES OF INTERVIEW Persuasive questions (persuade the patient to answer a √ Non - Directive Interview specific question) -Rapport - building interview Ex. -Controlled by the client You mentioned earlier that you cannot sleep, you mean to say because you drink coffee? Nondirective interviews The question is leading toward a specific type of answer Controlled by the patient This is used if patient is confused, so that patient can -although the nurse often needs to summarize and clarify the data Require more time answer properly (than directive interviews) Very effective at eliciting the patient's perceptions and feelings (controlled by the patient) FACTORS TO CONSIDER DURING THE Help identify what is important to the patient INTERVIEW Time Take note! When the client is physically comfortable and free of pain It is important to establish rapport Place -this will give enough information Well - lighted, well - ventilated room, free of noise and distractions Take note! Seating Arrangement Some patients talkative and they tell you unnecessary information Ideal seating arrangement : the nurse and patient sit in two chairs placed at right angles to a desk or a table or a few feet apart with no table What you will do? Initially Assess the patient if they are ready with the interview FACTORS TO CONSIDER DURING THE Explain the importance of interview INTERVIEW Learn how to end the interview √ Distance - Maintain a 2 to 3 feet distance during TYPES OF INTERVIEW interview √ Information Gathering Interview-Combination of non - directive and directive √ Language interview - Avoid medical jargon - Translators, interpreters TYPES OF INTERVIEW QUESTIONS Open ended THINGS TO AVOID DURING AN Closed Ended INTERVIEW Neutral √ Leading the patient Leading √ Biasing yourself √ Letting family members answer for patient√ Asking more than one question at a time√ Neutral Questions Not allowing enough response time A question that the client can answer without direction or pressure from the nurse Not bias Can you describe to me your situation at home? The patient can answer which are not biased Leading the patient Take note! THINGS TO AVOID DURING AN People will tell you what you want to hear INTERVIEW -so don't lead the patient √ Using medical jargon How to avoid leading the patient? √ Assuming rather than clarifying and Let him or her describe what is happening in his or her own validating words (much more helpful) √ Taking the patient's responses personally √ Feeling personally uncomfortable Biasing yourself √ Offering false reassurance Take note! √ Asking persistent or probing questions You can bias yourself because of the patient, a particular disease, or a particular physician √ Changing the subject (enhancing self-esteem, you take the credits) √ Taking things literally √ Giving advice Take note! √ Jumping to conclusions Give extra credit to physician -do not end up in conversation with negative impression by biasing yourself EXAMINING -have a fair treatment √ Physical Examination >Carried out systematically What is limited when you biased yourself? >Cephalocaudal or head to toe approach√ Screening Examination Being objective >Also called review of systems You focus not on the problem anymore >A brief review of essential functioning of various body parts or systems Take note! If you fail to check your biases ACTIVITIES OF DAILY LIVING -you limit your objectivity during assessment >Hygiene >bathing, grooming, shaving and oral care Letting family members answer for patient >Continence Take note! >Dressing You will learn a lot more by having the patient describe things >Eating in her or his own words the ability to feed oneself >Toileting Asking more than one question at a time the ability to use a restroom Take note! >Transferring If you do, the patient may not know which one to answer actions such as going from a seated to standing position and -or you may not be sure which question is being getting in and out of bed answered Do not make the patient is confused INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL] Not allowing enough response time >Finding and utilizing resources Take note! ​ looking up phone numbers, using a telephone, making and Give the patient time to think through his or her answer keeping doctors appointments This is especially important with older patients >Driving or arranging travel Not in a hurry ​ either by public transportation, such as Paratransit, or private car >Preparing meals Chief complaint ​ opening containers, using kitchen equipment."What is your major health problem.gf at this time?" Review of Systems >Skin, hair and nails History of present illness >Head and neck Using COLDSPA >Eyes Ears Mouth Character >Peripheral vascular. Onset >Abdomen Location Duration Severity Pattern >Male genitalia Associated factors >Thorax and lungs Breast and regional lymphatics >Female genitalia Past health hx >Anus, rectum, prost."What diseases did you have as a child?" >Musculoskeletal."What immunizations did you get and are you >Neurologic up to date now?" "What illnesses or allergies did you have? Complete Health Hx How were the illnesses treated?” >Groundwork for identifying nursing problems Family health hx > Importance lies in its ability to provide Familial diseases information that will assist the examiner in Nurses must be familiar with the field of genomics identifying areas of strength and limitation l >Provide the examiner with specific cues to Current medications health problems "What medications have you used inthe recent >Modified or shortened when necessary past and currently?"."For what purpose did you take the medication?."Do you take any medications not Steps ofHealth Assessment prescribed for you?" A.Collection of Subjective Data Through Lifestyle and health practices profile Interview and Health History Description of typical day Biographical data Nutritional and weight management Activity and exercise patterns Information that identifies the client Sleep and rest pattérns Client, immediate family, caregiver Substance use Format summary to obtain biographical data is Self-concept and self-care activities Social and community activities used Relationships Values and belief system Reasons for seeking health care Education and work "What is your major health problem of concetns Stress level and coping style at this time?" Environment "How do you feel about having to seek-health care?” Developmental level The primary source of data Váries depending on the patient's age and developmental level Psychosocial hx MATERIALS / EQUIPMENT Includes the way a person thinks, feels, acts and relates to self and others NEEDED The ability to cope and tolerate stress √ Height chart √ Weighing scale B. COLLECTION OF OBJECTIVE DATA √ Snellen's chart √ Penlight WHAT IS PHYSICAL √ Cardboard ASSESSSMENT √ Sterile gloves √ A systematic way of collecting objective data from a client using the four examination >Tongue depressor techniques >4x4 Gauze >tuning fork PURPOSE OF PHYSICAL > stethoscope ASSESSSMENT >wrist watch 1. Obtain physical data about the client's > tape measure functional abilities >marker/pencil r 2. Supplement, confirm, or refute data obtained >record sheet in the client's health history >waste receptacle 3. Obtain data that will help the nurse establish diagnoses and plan the client's care POSITIONING YOUR PATIENT 4. Evaluate the physiologic outcomes of health care and thus the progress of a patient's health problem STANDING 5. To make clinical judgments about a client's >Assessment of posture, gait & balance health status 6. To identify areas for health promotion and SITTING disease prevention >seated position, back unsupported and legs hanging freely >Head, neck, posterior and anterior thorax, breasts, axilla, upper extremities lower PREPARATORY PHASE extremities and reflexes 1. Introduce self to the client. Verify his identity. Explain the purpose why such procedure is necessary and DORSAL RECUMBENT how he could cooperate (i.e. positioning). >Back lying position with knees flexed and hips externally rotated; small pillow under 2. Help him put on a clean gown and offer a bedpan or the head; soles of the feet on the surface a urinal to empty his bladder. 3. Ensure privacy by closing the doors or pulling the SUPINE curtains around him. >The client is lying on the back. The head and shoulders are 4. Invite a relative or a significant other to stay with the usually elevated with a small pillow. The arms and legs are extended and the legs are client, as necessary slightly abducted 5. Provide adequate lighting. 6. Gather the Materials or Equipment. 7. Ensure the examination table is at a comfortable working height. Perform hand hygiene. SIM'S >The client is lying on the side with the body turned at 45 degrees. >The lower leg is extended, with the upper leg flexed at the hip and knee to a 45 to 90 degree angle. PRONE >The dorsum, or back of the hand, is used to assess surface temperature >The client is lying on the abdomen with head turned to the side. LIGHT PALPATION LITHOTOMY >Place the hand with fingers together parallel moving the hand in circle.1/2 inch (1 cm) >The client is lying on the back with the hips and knees flexed at right angles and feet in muscle tone tenderness stirrups. DEEP PALPATION KNEE CHEST >1inch (2 cm). >Assessment of rectal area >abdominal organs and abdominal masses. >Two - handed deep palpation place the fingers of one hand on top of those of the other. Techniques of physical Assessment.The top hand applies pressure while the lower hand remains relaxed to perceive the tactile sensation. ORDER OF EXAMINATION AREAS >pressure can damage internal organs. 1. ADULT √ Deep Palpation is done Cephalocaudal with two hands (bimanually) or one hand 2. PEDIA √ Least invasive to more invasive areas PERCUSSION √ Striking of the body surface with short, sharp strokes ASSESSMENT TECHNIQUES √ palpable vibrations and characteristic sound. 1.Inspection(I) √ location, size, shape 2.Palpation (P) √ density of underlying structures 3.Percussion (P) √ to detect the presence of air or fluid in a body space 4.Auscultation (A) √ elicit tenderness. INSPECTION TYPES OF PERCUSSION >Visual examination of the patient done in a methodical, deliberate, 1. DIRECT PERCUSSION purposeful, and systematic manner. >using sharp rapid movements from the wrist, strike the body surface to be percussed >Careful observation with the pads of two, three, or four fingers or middle finger alone √ PROPER Tangential lighting is necessary √ Begins with the initial contact and continues all throughout the assessment 2. INDIRECT PERCUSSION √ moisture, color and texture of the body surfaces, aswell as shape, position, size, color, > Percussion in which two hands are used and the plexor strikes the finger of the and symmetry ofthe body. examiner's other hand, which is in contact with the body surface being percussed PALPATION PERCUSSION sense of touch. TECHNIQUE √ The use of hand to touch and feel the patient's skin, organs, mass, and other √ Strike at a right angle to the pleximeter using quick, sharp but delineated structures in the body. relaxed wrist motion Assess temperature; turgor; texture; moisture; vibrations; position, size, shape, √ Withdraw the plexor immediately after the strike to avoid damping the vibration. Strike consistency and mobility of organ or masses; distention; pulsation; and the each are twice and then move to a new area presence pain upon pressure PERCUSSION Types Of Sounds Heard When Percussing Palmar surfaces of the FLAT - soft >examiner's fingertips and finger pads are used for discriminatory sensation, such as DULL - medium texture, vibration, presence of fluid, or size and consistency.of a mass RESONANCE - loud  HYPER RESONANCE - very loud Blood chemistry TYMPANY- loud Metabolic screening. CBG AUSCULTATION Stool specimen √ Listening to sounds produced within the body Urine specimen √ CHARACTERISTICS OF SOUND HEARD DURING Indwelling catheter AUSCULTATION Sputum Specimen PITCH - Ranging from high to low Throat culture LOUDNESS - ranging from soft to loud Dx Imaging studies QUALITY - gurgling or swishing DURATION - short, medium or long Other Sources >Use the bell of the stethoscope to detect low- pitched sounds. Client chart / Medical record >The bell should be at least 1 inch wide. Family or SOs >Hold the bell lightly against the body part being auscultated. >Use the diaphragm of the stethoscope to detect high-pitched sounds. >The diaphragm should be at least 1.5 inches wide for adults and smaller for children. >Hold the diaphragm firmly against the body part being auscultated. Diagnostic Tests & Procedures Diagnostic Tests Lab tests Basic screening Confirm diagnosis, monitor an illness, and provide valuable information about the client's response to treatment Phases > Pre-test >Intra-test >Post-test Diagnostic Tests Appropriate Nursing Diagnosis >Anxiety or fear >Impaired physical mobility > Deficient knowledge Common Diagnostic Tests Blood tests CBC Serum electrolytes ABG