Chapter 6 Assessment - Notes from Fundamentals of Nursing Yoost/Crawford PDF

Preview

Summary

Notes from Fundamentals of Nursing Yoost/Crawford...

Description

!

CHAPTER 6: ASSESSMENT ! ! KEY TERMS! auscultation - Listening, with the assistance of a stethoscope, to sounds within the body.! cue - A hint or an indication of a potential disease process or disorder.! health history - Includes all pertinent information collected during initial or early contact with a patient that can guide the development of a patient-centered plan of care.! inferences - Conclusions.! inspection - The use of vision, hearing, and smell to closely scrutinize physical characteristics of a whole person and individual body systems.! objective data - Data that can be measured or observed. The nurse's senses of sight, hearing, touch, and smell are used to collect objective data. Also called signs.! palpation - Physical examination using touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness.! patient interview - A formal, structured discussion in which the nurse questions the patient to obtain demographic information,! as well as data about current health concerns and past medical and surgical history.! percussion - Tapping the patient's skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures.! primary data - Data that comes directly from the patient.! secondary data - Information about a patient shared by family members, friends, or other members of the health care team.! signs - Data that can be measured or observed. the nurse's senses of sight, hearing, touch, and smell are used to observe signs; also called objective data.! subjective data - Spoken information that is difficult to authenticate. Generally, subjective data are gathered during the! interview process if patients are well enough to describe their symptoms.! symptoms - Subjective description of a disease process or problem by a patient.! ! The nurse may use the following methods for assessment:! • Observation • Patient interview - The patient interview consists of three phases: orientation (introductory), working, and termination. During the orientation phase of the interview, the nurse should establish the name by which the patient prefers to be addressed. Demographic data should be collected by asking focused or closed-ended questions. More general information can be gathered by open-ended communication techniques. When feasible, the nurse and the patient should be seated at eye level with each other.

! Three kinds of physical assessments:! • Comprehensive/complete - includes a thorough interview, health history, review of systems, and extensive physical head-to-toe assessment, including evaluation of cranial nerves and sensory organs, such as with sight and hearing testing. ! • Clinical/focused - conducted when signs indicate a change in a patient’s condition or the development of a new complication.! • Emergency - physical examination done when time is a factor, treatment must begin immediately, or priorities for care need to be established in a few seconds or minutes. Attention is paid to the patient’s airway, breathing, and circulation (ABC’S); compound fractures, contusions, abrasions, puncture wounds, burns, tenderness, lacerations, bleeding, and swelling! ! Triage: Level 1 is considered critical: life-threatening conditions require immediate and continuous care such as severe trauma, cardiac arrest, respiratory distress, seizure, or shock. Level 2 emergencies can be imminently life-threatening conditions requiring care within 30 minutes, such as chest pain or major fractures, with severe pain. Level 3 is considered urgent: potentially lifethreatening conditions that require care within 30 to 60 minutes, such as minor fractures, lacerations, and dehydration. Level 4 is considered semi-urgent, stable health conditions that require care within 60 to 120 minutes, such as a twisted ankle. Level 5 conditions are non-urgent and lower risk such as cold symptoms.! ! Data Organization:! • Body Systems Model - physical aspects, body systems, like medical model for physical examination • Head To Toe Model - ensures all areas of concerns are addressed! • Functional Health Patterns - holistic approach ! ! ! ! ! ! ! ! !...