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Physical Assessment Exam 1 - Coggle Diagram
Physical Assessment Exam 1
Chapter 1 - Evidence Based Assessment
Physical Assessment 101
The Nursing Process
3) Plan
4) Implement
2) Diagnose/Analyze
5) Evaluate
1) Assess
Subjective = what a patient says
Objective = what you/another provider observes
Critical Thinking = creativity + pattern recognition + reflective reasoning
Priority Setting
2) urgent but not life-threatening
3) Important but can be addressed later
1) ABC's and V&L
Evidence-based clinical decisions (4 factors)
literature review
patient preferences
clinician expertise
physical assessment
Data Types
Complete
Focused/Problem-based
Follow-up - treatment evaluation
Emergency - rapid gathering
Holistic Health - health of the mind, body, and spirit
Chapter 3 - The Interview
Interviews 101
Types of Data
Objective
Subjective
First Point of Contact - first and most important step
Components of a Successful Interview
Complete and Accurate Data
Trust and Rapport
Teaching
Problem identification
Health promotion and Disease Prevention
Closing the Interview
be graceful and clearly indicate the end
summarize
ensure clarity
say thank you
Note-taking might be an issue, so try to minimize it
Patient is always in charge and make sure to establish expectations
Communication
Factors of Communication
Internal - specific to examiner
liking/respecting others
empathy
External
Privacy
Refuse/limit interuptions
Environment
Provider appearance
Recording = tape, video, or notes
Verbal cue are important too~!
Non-verbal
Vocal - pitch, tone, quality
Action cues - posture, expression, eye contact, gestures
Object cues - physical apperance, clothing, jewelry, and hairstyle
Personal space
Touch
Success = mutal understanding for all parties
Receiving is based on client's personal experience with life
Communication Techniques
Open-Ended Questions - anything but a yes or no question, facilitates elaboration
Close-ended Questions - yes or no questions, best avoided unless the patient is very stressed
General Techniques
address patient by surname
make greeting short and formal
introduce yourself and your role
give reason for the interview
How to Get Good Information (9 tips)
facilitate elaboration
silent attentiveness
reflection/repeating
empathy
clarification
confrontation
interpretation
explain
summarize
What are the 11 Traps of Interviewing
false reassurance
giving unwanted advice
using authority
using avoidance language
distancing
professional jargon
leading or biased questions
too much talking
interruptions from you
why questions
not being aware of your own baggage
Special Considerations
Developmental
acknowledge patient and caregiver
adolecents need respect, validation, and positive reinforcement
Elderly people do not want elderspeak, rushing, or to be addressed by first name
Social
gender
culture
sexual orientation
need of interpreter
written materials
teachback
personal space
Chapter 4 - Health History
Health History Sequence
Biographical data
Source
Reason for visit
History of Present Illness
Past Health
Childhood illness (or last 5 years for elderly)
Accident/Injury
Serious or chronic illnesses
Hospitalizations
Operations
Obstetric History (GPTAL)
Immunizations
Allergies
Medications
Last exam date
Family History
ROS
Overall
Integumentary
Gastrointestinal
Respiratory
Cardiovascular
Urinary
Reproductive
Musculoskeletal
Neurological
Hematological
Endocrine
Functional Assessment (ADL's)
Self-esteem/comcept
CREATION Health
E = Environment/Work Hazards
A = Activity
R = Rest
T = Trust = Spiritual resources and coping = FICA
C = Choice = Personal Habits
I = Interpersonal Relationships
O = Occupational Health
N = Nutrition/Elimination
Drug and alcohol abuse
Intimate partner violence
Pain Assessment
P = Provocative/Palliative
Q = Quality
R = Region/Radiating
S = Severity
T = Timing/Onset
U = Understand the patient's perception of the problem
Associated Factors - is it associated with any other symptoms?
Special Considerations
The Elderly Patient
may have chronic illnesses
Polypharmacy - make sure to record all med every time
get date of last exam
obstetric history
allergies
Chapter 8 - Assessment Techniques and Safety
Physical Assesment
Purposes
Screening
Validation
Monitoring
Diagnosis
Components (in order) (EXCEPT BOWELS: You auscultate THEN palpate)
1) Inspection
Always occurs first
Compare for symmetry
Requirements
Good lighting
Adequate Exposure
Some instruments - penlight, otoscope, and opthamoscope
2) Palpation
What are we assessing?
Texture
Temperature
Moisture
Organ location and size
Swelling, vibration, or pulsation
Rigidity or Spasticity
Spasticity - how joints move, abnormal muscle stiffness due to CNS damage
Crepitation
Lumps
Pain or Tenderness
Keep patient informed
Warm hands, short nails
encourage normal breathing
discontinue if painful
Techniques
Fingertips - tactile discrimination
Fingers + Thumb = position, shape, and consistency
Dorsa of hands - temperature
Base of Fingers/ Ulnar Surface = vibration
Go from light to deep
deep = 4-5cm in depth, used in abdominal and reproductive assessments
Bimanual = 2 hands
3) Percussion = ALWAYS DEFER
4) Auscultation
Bell = low pitched sounds, ex: heart murmur, bruit
Diaphragm = high-pitched sounds, ex: heart, breath, bowel
Confusing Artifacts
room noise
shivering
friction
own breathing
Safety
wash hands
before and after patient contact
after contact with bodily excretions
after contact with contaminated equiment
after removing gloves
wear gloves
The Clinical Setting
reduce anxiety by being calm and confident
start with the person's hands
keep the same order every time doing one step at a time
teach patient along the way
Special Considerations
Adolescents want feedback and a focus on personal wellness
Elderly
Be very organized
Allow rest periods
Take your time
Golden Rules
stay on the right
head to toe
compare for symmetry
least invasive to most invasive
use the same systemic approach every time