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ARIZONA COLLEGE NUR 216 - Health M1 Notes

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Introduction to Assessment Assessment ● 1st step in nursing process ○ Continuous data collection ● Thinking process ○ essentials in critical thinking: Intellectual integrity, justice, and perseverance, and faith in reason ● Critical thinking skills ○ divergent thinking - analyzing different pov ○ reasoning - differentiating facts from assumptions ○ reflection - consider "if...then" possibilities ○ creativity - think outside the box ○ clarification - address assumptions, comparing, contrasting ○ basic support - evidence based practice ● Doing process ○ 4 techniques of physical assessment: ■ Inspection, palpation, percussion, auscultation ● Feeling process ○ skills needed to develop caring, nurse-client relationship ● ethical skills: ○ responsible and accountable for practice ○ patient advocate ■ respect clients rights ○ assure confidentiality ■ HIPAA General survey ● age, gender, race, affect, level of consciousness, dress, posture, speech, and obvious abnormalities or signs of distress Documentation ● accurate, concise, objective, record by systems, chart pertinent negatives Levels of Preventative Care ● Primary - focus on health promotion and prevention ● Secondary - focus on early detection, prompt intervention and health maintenance ● Tertiary - focus on rehabilitative, extended, or end of life care Data ● Types ○ subjective - what the patient tells you is feeling, symptoms ○ objective data - measurable, observable, signs ● Sources ○ primary - patient ○ secondary - family member, healthcare providers, friends ● Prioritizing data ○ primary - life threshing problems■ eg. airway obstruction ○ secondary - require prompt attention to prevent further deterioration ○ tertiary - important, does not require immediate attention ■ eg.patient education Communication tips ● SBAR ○ S - situation ○ B - background ○ A - assessment ○ R - recommendation Vital Signs ● temperature, pulse, respirations, pulse oximetry, blood pressure, height, weight, body mass index Head to Toe Approach ● integumentary, HEENT, breast, respiratory, cardiovascular, gastrointestinal, , neurological, genitourinary/reproductive Documentation ● SOAPIE ○ S - subjective data ○ O- objective data ○ A-assessment ○ P-plan ○ I-intervention ○ E- evaluation ● DAR ○ D - data ○ A - action ○ R - response ● PIE ○ P - problem ○ I - intervention ○ E - evaluation Physical Assessment ● Inspection ○ Types: ■ direct - direct visualization ■ indirect - using a light source or magnifier for visualization ○ Senses: sight, smell ○ Data: surface characteristics, symmetry, gross abnormalities, signs of distress, unusual odor ● Palpation ○ Types: ■ direct - single handed or bimanual ■ light - indenting the skin <1 in■ deep - indenting the skin >1 in ■ ballottement - access partially free floating objects ○ Different parts of the hand are best ■ dorsal aspect - assess change in temperature ■ balls and ulnar surface - assess vibrations ■ finger tips - assess fine sensations ○ Sense: touch ○ Data: ■ light - surface characteristics ● eg.temperature and texture ■ deep - organs, masses, tenderness ■ ballottement - size, shape of partially free floating object ● eg.fetal position ● Percussion ○ Types: ■ direct - tapping over the body surface to elicit a sound or area of tenderness ■ indirect - placing nondominant hand over body surface, striking to elicit a sound or area of tenderness ■ fist or blunt - directly or indirectly striking the body surface to note area of tenderness ○ Senses: touch or hearing ○ Data: direct or indirect ■ density, size and shape, tenderness, deep tendon reflexes ○ Percussion sounds: ■ resonance - low, loud, long ■ hyperresonance - very low,loud, and long ■ dull - high, soft, short ■ flat - very high, soft, and short ■ tympany - medium ○ Fist/blunt: tenderness ● Auscultation ○ Types: ■ direct - directly listening for sounds ■ indirectly - using a stethoscope to hear sounds ○ Stethoscope types ■ single head - pressure sensitive to detect high (apply heavy pressure) and low (apply light pressure) pitch sounds ■ combination head with bell and diaphragm - flat side for high pitched sounds, cone shaped for low pressure ○ Senses: hearing ○ Data: heart sounds (H, M, L), Lung sounds (H), bowel sounds (H), vascular sounds (L) Complete Health History○ Biographical Data ■ name, address, phone number, contact person, age, birth date, gender, race, marital status, number of dependents, educational level, occupation, social security, health insurance, advance directive ○ Current Health Status ■ symptom analysis of chief complaint and current medications, allergies with reaction ○ Past Health History ■ childhood illnesses, surgeries, hospitalizations, serious injuries, immunizations, and recent travel or military service ○ Family History ■ includes: patient, spouse, children, siblings, parents, uncles, and grandparents ■ if grandparents are deceased include: age and cause of death ○ Psychosocial Profile ■ includes: health practices and beliefs, typical day, nutritional patterns, exercise, recreation, hobbies, pets, sleep, personal habits, socioeconomic status, environmental health patterns, relationships, sexuality, social support, coping Complete Health Assessment ● Approach ○ system - allows for through assessment of each system, better for focus assessment ○ head to toe - assess each region of the body, better for complete assessment ● General Survey ○ get vital signs, evaluate patients clothing, hygiene, state of wellbeing, nutritional status, emotional status, speech patterns, level of consciousness, affect, posture, gait, coordination and balance, and gross deformities ○ Vital Signs ■ Newborns ● temp - 98.6 to 99.8F ● pulse - 120 to 160 ● respiratory - 30 to 80 ● BP - 50/25 ■ Child ● temp - 97.5 to 98.6F ● pulse - 70 to 110 ● respiratory - 16 to 22 ● BP - 90/70 ■ Young Adult ● temp - 97.6 to 98.8F ● pulse - 55 to 100 ● respiratory - 15 to 20 ● BP - 105/60■ Adult ● temp - 96.8 to 99.5F ● pulse - 60 to 100 ● respiratory - 12 to 20 ● BP - 120/80 ■ Older Adult ● temp - 96.5 to 97.5F ● pulse - 60 to 100 ● respiratory - 12 to 20 ● BP - 120/80 ● Review of Systems ○ General: usual state of health, weakness,


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