Physical Assessment

1. Physical Assessment An Overview J. Carley RN, MSN, MA, CNE Fall, 2009

2. Plan of the Day 9/1/2009 √ Introduction to Block 2 √ Introduction to Health Assessment (~0800-0900) √ Interviewing / Documentation (~0900-1000) √ Review of Systems (~1000-1100) Lunch (1200-1500) √ Hand washing √ Review of Systems / Health History Interview with partner (p. 33-40 in Jarvis Student Laboratory Manual) ***Complete & Turn it in! Before You Leave Today

3. We’re Late !Let’s Start Report….

4. “New Admission” Today’s Census = 10 [Staffing: 1 RN (You!) , 1 LVN (O), 1 CNA] RN’s Comment: “Oh, *&%$#!!!”

5. But First, Let’s Introduce Some Background, or ………CONTEXT ! You’ll see the patients on the previous page in Adult Health II……………………………..

6. Content and Process of This Course ! mnemonic “A-D-O-P-I-E” Nursing Process Assessment Diagnosis Outcome Identification Planning Intervention Evaluation List of NANDA Nursing Diagnoses

7. Nursing Process • A Closer Look http://usnnursing.pbworks.com/Physical-Assessment-Page

8. Assessment Collect Data: √ Review the Clinical Record √ Interview √ Health History √ Physical Examination √ Functional Assessment √ Consultation * Review of the Literature (--Evidence Based Practice)

9. Diagnosis *Interpret Data: √ Identify clusters / cues √ Make Inferences * Validate Inferences * Compare clusters of cues w/ definition, defining characteristics * Identify Related Factors * Document the nursing diagnosis

10. Outcome Identification --Identify expected outcomes --INDIVIDUALIZE to the person --Realistic and MEASURABLE --Include a TIME FRAME

11. Planning --Establish priorities --Develop Outcomes --Set time frames for outcomes --Identify Interventions --Document Plan of Care “The Nursing Care Plan”

12. Implementation --Review planned interventions --Schedule & coordinate patient’s care --Collaborate w/ other team members--Supervise implementation by delegation --Counsel patient & family --Involve the patient in their care --Referrals as need for continuity of care --Document care provided

13. Evaluation --Refer to the outcomes you established --Evaluate individual’s condition: compare actual outcomes to expected outcomes --Summarize results of the evaluation--If expected outcomes not met, identify reasons --Modify Plan of Care as necessary --Document Evaluation of Outcomes, and changes (if any) in Plan of Care

14. Nursing Process Assessment Diagnosis Outcome Identification Planning Intervention mnemonic “A-D-O-P-I-E” Evaluation

15. The Interview & Types of Data Subjective Data Objective Data

16. Objective Data: • Blood Pressure = 142 / 98 mm Hg • Weight = 158 lbs (= 71.8 kg) • Oral Intake = 2400 mL / 24 hours • Urinary Output = 250 mL / 24 hours • Imbalance Between Oral Intake & Urinary Output (above) “Stuff You can Actually See and Measure”

17. The Interview “Yes.” “Uh Huh.” “I see…”

18. Subjective Data The Interview • During the interview, it is a chance for the patient to tell you how he or she PERCEIVES what is going on—what they THINK (or want you to think) their health state is…

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22. Part 2:Interviewing & Documentation The Nursing Interview

23. “The Nursing Process…” • Mnemonic: “ADOPIE” = “The Nursing Process” Assessment Diagnosis Evaluation Outcome Identification Implementation Planning

24. Establish Rapport • Get organized • Do not rely on memory • Plan enough time • Ensure privacy • Get focused • Be calm, confident, warm, and helpful

25. Begin the Interview • Give your name and position • Verify the client’s name • Briefly explain your purpose

26. How to listen • Be an empathetic listener • Use short supplementary phrases • Listen for feelings as well as words • Let the person know when you see body language that conflicts with what they say • Be patient if the patient has a memory block • Avoid the impulse to interrupt • Allow for pauses

27. How to ask Questions • Ask about the main problem first = chief complaint • Focus your questions to gain specific information about the signs and symptoms • Don’t lead the witness • Restate the other person’s words to clarify • Use open-ended questions • Avoid closed –ended, yes or no questions

28. How to terminate the interview • If the session has been long, give a warning • As the person to summarize their primary concerns • Ask if there are other areas to be discussed • Offer yourself as a resource • Explain routines and provide information about who does what • End on a positive note

29. Charting & Documentation • If it isn’t written, then it wasn’t done • Chart at the time it occurs – if possible • Follow facility guidelines • Is the information clear and logical? • Is it true? • Is it non - judgmental? • Record all abnormals and normals

30. Charting guidelines • Be precise • Stick to the facts • Sign your name after each entry • SOAP format – focuses on specific problems • AIR, DAR, PIE, DIE formats – focus on nursing interventions and client response • Prioritize the client problems

31. Part Two: Complete Health History • Biographical Data • Reasons for Seeking Health Care • History of Present Health Concern • Past Health History • Family Health History

32. Lifestyle and Health Practices Profile • Description of Typical Day • Nutrition and Weight Management • Activity Level and Exercise • Sleep and Rest • Medication and Substance Use • Self-Concept • Self-Care Responsibilities

33. NANDA Nursing Diagnosis List Activity IntoleranceActivity Intolerance, Risk forAirway Clearance, IneffectiveAnxietyAnxiety, DeathAspiration, Risk forAttachment, Parent/Infant/Child, Risk for ImpairedAutonomic DysreflexiaAutonomic Dysreflexia, Risk for Blood Glucose, Risk for UnstableBody Image, DisturbedBody Temperature: Imbalanced, Risk forBowel IncontinenceBreastfeeding, EffectiveBreastfeeding, IneffectiveBreastfeeding, InterruptedBreathing Pattern, Ineffective

34. Cardiac Output, DecreasedCaregiver Role StrainCaregiver Role Strain, Risk forComfort, Readiness for EnhancedCommunication: Impaired, VerbalCommunication, Readiness for EnhancedConfusion, AcuteConfusion, Acute, Risk forConfusion, ChronicConstipationConstipation, PerceivedConstipation, Risk forContaminationContamination, Risk forCoping: Community, IneffectiveCoping: Community, Readiness for EnhancedCoping, DefensiveCoping: Family, CompromisedCoping: Family, DisabledCoping: Family, Readiness for EnhancedCoping (Individual), Readiness for EnhancedCoping, IneffectiveDecisional Conflict

35. Decision Making, Readiness for EnhancedDenial, IneffectiveDentition, ImpairedDevelopment: Delayed, Risk forDiarrheaDisuse Syndrome, Risk forDiversional Activity, Deficient Energy Field, DisturbedEnvironmental Interpretation Syndrome, Impaired Failure to Thrive, AdultFalls, Risk forFamily Processes, Dysfunctional: AlcoholismFamily Processes, InterruptedFamily Processes, Readiness for EnhancedFatigueFearFluid Balance, Readiness for EnhancedFluid Volume, DeficientFluid Volume, Deficient, Risk forFluid Volume, ExcessFluid Volume, Imbalanced, Risk for

36. Gas Exchange, ImpairedGrievingGrieving, ComplicatedGrieving, Risk for ComplicatedGrowth, Disproportionate, Risk forGrowth and Development, Delayed Health Behavior, Risk-ProneHealth Maintenance, IneffectiveHealth-Seeking Behaviors (Specify)Home Maintenance, ImpairedHope, Readiness for EnhancedHopelessnessHuman Dignity, Risk for CompromisedHyperthermiaHypothermia Immunization Status, Readiness for Enhanced

37. Infant Behavior, Disorganizednfant Behavior: Disorganized, Risk forInfant Behavior: Organized, Readiness for EnhancedInfant Feeding Pattern, IneffectiveInfection, Risk forInjury, Risk forInsomniaIntracranial Adaptive Capacity, Decreased Knowledge, Deficient (Specify)Knowledge (Specify), Readiness for Enhanced Latex Allergy ResponseLatex Allergy Response, Risk forLiver Function, Impaired, Risk forLoneliness, Risk for

38. Memory, ImpairedMobility: Bed, ImpairedMobility: Physical, ImpairedMobility: Wheelchair, Impaired Moral Distress NauseaNeurovascular Dysfunction: Peripheral, Risk forNoncompliance (Specify)Nutrition, Imbalanced: Less than Body RequirementsNutrition, Imbalanced: More than Body RequirementsNutrition, Imbalanced: More than Body Requirements, Risk forNutrition, Readiness for Enhanced Oral Mucous Membrane, Impaired

39. Pain, AcutePain, ChronicParenting, ImpairedParenting, Readiness for EnhancedParenting, Risk for ImpairedPerioperative Positioning Injury, Risk forPersonal Identity, DisturbedPoisoning, Risk forPost-Trauma SyndromePost-Trauma Syndrome, Risk forPower, Readiness for EnhancedPowerlessnessPowerlessness, Risk forProtection, Ineffective Rape-Trauma SyndromeRape-Trauma Syndrome: Compound ReactionRape-Trauma Syndrome: Silent Reaction

40. Religiosity, ImpairedReligiosity, Readiness for EnhancedReligiosity, Risk for ImpairedRelocation Stress SyndromeRelocation Stress Syndrome, Risk forRole Conflict, ParentalRole Performance, Ineffective Sedentary LifestyleSelf-Care, Readiness for EnhancedSelf-Care Deficit: Bathing/HygieneSelf-Care Deficit: Dressing/GroomingSelf-Care Deficit: Feeding Self-Care Deficit: ToiletingSelf-Concept, Readiness for EnhancedSelf-Esteem, Chronic LowSelf-Esteem, Situational LowSelf-Esteem, Risk for Situational LowSelf-MutilationSelf-Mutilation, Risk for

41. Sensory Perception, Disturbed (Specify: Auditory,Gustatory, Kinesthetic, Olfactory Tactile,Visual) Sexual DysfunctionSexuality Pattern, IneffectiveSkin Integrity, ImpairedSkin Integrity, Risk for ImpairedSleep DeprivationSleep, Readiness for EnhancedSocial Interaction, ImpairedSocial IsolationSorrow, ChronicSpiritual DistressSpiritual Distress, Risk forSpiritual Well-Being, Readiness for EnhancedSpontaneous Ventilation, ImpairedStress, OverloadSudden Infant Death Syndrome, Risk forSuffocation, Risk for

42. Suicide, Risk forSurgical Recovery, DelayedSwallowing, Impaired Therapeutic Regimen Management: Community,IneffectiveTherapeutic Regimen Management, EffectiveTherapeutic Regimen Management: Family,IneffectiveTherapeutic Regimen Management, IneffectiveTherapeutic Regimen Management, Readiness for EnhancedThermoregulation, IneffectiveThought Processes, DisturbedTissue Integrity, Impaired Tissue Perfusion, Ineffective (Specify: Cerebral,Cardiopulmonary, Gastrointestinal, Renal) Tissue Perfusion, Ineffective, PeripheralTransfer Ability, ImpairedTrauma, Risk for

43. Unilateral NeglectUrinary Elimination, ImpairedUrinary Elimination, Readiness for EnhancedUrinary Incontinence, FunctionalUrinary Incontinence, OverflowUrinary Incontinence, ReflexUrinary Incontinence, StressUrinary Incontinence, TotalUrinary Incontinence, UrgeUrinary Incontinence, Risk for Urge Urinary Retention Ventilatory Weaning Response, DysfunctionalViolence: Other-Directed, Risk forViolence: Self-Directed, Risk for Walking, ImpairedWandering

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