Chapter 6 - Assessment - These are notes from Fundamentals of nursing. PDF

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These are notes from Fundamentals of nursing....

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Chapter 6 – Assessment Vocabulary •

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Subjective data – spoken symptoms that are difficult to validate. o Can be from pt or family, friends, other members of health care team. o If from anyone other than pt, it is considered secondary Objective date – signs that can be measures or observed. o Nurses sense of sight, hearing, touch and smell can collect objective data Cue – a hint or indication of potential problems or disease o Ex: a pt winces, it may indicate pain. A pt resists being touch, may indicate victim of physical abuse

Explain the phases of a patient interview 1. Orientation a. Establish name pt prefers b. Provide introduction and state purpose of interview c. Establish trust between pt and nurse d. Demographics are collected e. Identifying pt needs f. Nurse should sit at eye level 2. Working phase a. Nurse individualizes the process on the basis of health of pt and concerns that emerge during interview b. Stay alert to how the pt gives information, not only what they’re saying c. Watch for emotional cues, such as fear, anxiety, sadness d. Educational needs are assessed e. Ask focused and closed ended questions when collecting data i. Ask open ended if you need to expand on info f. Health history is collected g. Review of each body system h. Asking assessment questions for each system 3. Termination phase a. Summarizing with pt b. Allowing pt to add any last minute details or ask questions c. Acknowledge pt participation and explain next steps For each sense, identify what info a nurse can gather 1. Sight – physical appearance, gait, movement, coloration, skin integrity, moisture, dryness, edema, facial expressions, posture 2. Hearing – infliction in voice, wheezing, coughing, crying, cardiopulmonary and abdominal sounds 3. Touch – skin temp, moisture, edema, discomfort. Abdnormal growths 4. Smell – body and breath odors, body elimination

Heath History Data •

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Demographic o Name, address, tele, age, dob, birthplace, gender, marital status, race, cultural background, religion, edu level, occupation Chief of complaint o Reason for seeking care, onset of symptoms Allergies o Meds, food, environment o Reactions to these allergens (rash, dyspnea, nausea) Medications o Meds, vitamins, herbal supp o Dosage, freq, reason for use Immunizations o Childhood and adult o Date of last tb test o Date of last vaccine (flu, pneumonia) Med hx o Childhood illnesses, accidents, chronic illnesses o Hospilitizations, including obstetric hx o Date of occurrence and current tx Sx hx o Type of sx o Date o Any complications? Problems with anesthesia? Family hx o Age and health of living parents o Genetic diseases Social hx o Use of tobacco, drugs, alcohol o Environmental exposures o Safety concerns (domestic abuse, emotional abuse) o Recent foreign travel Cultural o Lang o Diet restrictions o Religion o Values and beliefs related to health care ADL o Nutrition o Caffeine o Self care activities (bathing, grooming, ambulation) o Use of prosthetics o Sleep patters Cognitive or emotional status o Cognitive functioning o Self esteem o Support groups

Explain the differences between comprehensive, focused, and emergency assessments 1. Comprehensive a. Thorough interview, health hx, review of all systems, extensive head to toe, sight and hearing testing b. Include lab and diagnostic tests ordered by doc c. Can be conducted on admission to hospital, during annual physical, initial interaction with a specialist 2. Focused a. Brief individualized physical exam conducted at the beginning of an acute care shift to established current pt status, during ongoing encounters, or when signs indicate a change in pt status b. Most common type conducted by nurse c. Think of like a pt at a hospital 3. Emergency a. Time is factor, tx must begin immediately b. Quick survey of what happened and then focused physical exam on critical injuries, symptoms, or signs c. Pt responsiveness is determined d. Focus on ABC…airway, breathing, circulation e. Must be reassessed every 5-15 minutes In regards to data organization, what are different way to organize it 1. Body system model: doing an assessment and taking the data system by system a. Murders Linc b. Muscular Urinary Reproductive Digestive Endocrine Respiratory Skeletal Lymphatic Integumentary Nervous Circulatory 2. Head to toe a. Literally from cephalic to caudal 3. Gordons Functional Health Pattern a. Marjory Gordon developed health patters to look at pt strength b. Nutrition/metabolic, elimination, sleep/rest. Cognitive, sexuality/reproductive, values/beliefs c. Ex: activity and exercise, that would focus on cardiac, respiratory, musculoskeletal Diversity Consideration •

Life span o Veterans respect authority, relationship oriented, communicate in discrete respectful way, may be slow to warm up o Baby boomers are optimistic, communicate openly and direct, expect detailed info, share information frequently and value time o Gen x (1965-76) are informal, tech immigrants, multitask, communicate in short, blunt, factual ways, value time o Millennials are flexible, techy, communicate with action verbs and humor, like personal attention o Gen z (1995-2012) value group work, digitally connected, want immediate feedback, accepting of others, value honesty, close to family...