Physical Assessment

J. Carley RN, MSN, MA, CNEFall, 2009

An Overview

You’re Late !Let’s Start Report….

Rm. 3A: Velma Aguon

76 y.o. P.I.-Am. Female

DX: Hypertensive Crisis

Rm. 4A:Mike Smithe

32 y.o. Afr-Am Male

DX: R/O M.I., HTN

Rm. 5A:Julian Reilly 44 y.o. Cauc.

Male

DX: Pericarditis

Rm. 6A:Ashley Wilkes

26 y.o. Cauc.

Female

DX: Mitral Stenosis

Rm. 7A:Emsley Owens

72 y.o. Afr-Am

Male

DX: CHF

Rm. 8A:Redd Butler

56 y.o Cauc.

DX: Cardiomyopathy,

CHF

Rm. 9A:Faith Hopee

78 y.o. N.A.

Female

DX: A- Fib

Rm. 10A:Frank Arbugast

18 y.o. Afr-Am

Male

DX: Sickle-Cell Cr.

Rm. 11A:Aubrey Embry

38 y.o. J.A.

Female

DX: Endocarditis

Rm. 12A:Yolanda Zahara

55 y.o. M.E. A.

Female

DX: Buerger’s Disease

“New Admission”

RN’s Comment: “Oh, *&%$#!!!”

Nursing ProcessAssessme

nt

Diagnosis

Outcome Identificati

on

Planning

Intervention

mnemonic

“A-D-O-P-I-E”

List of NANDA Nursing Diagnoses

Content and Processof This Course !

Evaluation

The Nursing Process

• A Closer Look

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

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

Outcome Identification

--Identify expected outcomes

--INDIVIDUALIZE to the person

--Realistic and MEASURABLE

--Include a TIME FRAME

Planning

--Establish priorities --Develop Outcomes --Set time frames for outcomes --Identify Interventions --Document Plan of Care

“The Nursing Care Plan”

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

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

Nursing Process

Assessment

Diagnosis

Outcome Identificati

on

Planning

Intervention mnemonic

“A-D-O-P-I-E”Evaluatio

n

Subjective DataObjective Data

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)

The Interview

“Yes.”

“Uh Huh.”

“I see…”

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…

U2: Your Blue Roomhttp://www.youtube.com/watch?v=xS4hJabqRc4

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Learning Games

Part 2:Interviewing & Documentation

The Nursing Interview

“The Nursing Process…”

• Mnemonic: “ADOPIE” = “The Nursing Process”

Assessment

Diagnosis

PlanningImplementation

Evaluation

OutcomeIdentification

Establish Rapport

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

helpful

Begin the Interview

• Give your name and position

• Verify the client’s name

• Briefly explain your purpose

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

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

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

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

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

Part Two: Complete Health History

• Biographical Data• Reasons for Seeking Health Care• History of Present Health Concern• Past Health History• Family Health History

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

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

NANDA Nursing Diagnosis List

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

Decision Making, Readiness for EnhancedDenial, IneffectiveDentition, ImpairedDevelopment: Delayed, Risk forDiarrheaDisuse Syndrome, Risk forDiversional Activity, DeficientEnergy Field, DisturbedEnvironmental Interpretation Syndrome, ImpairedFailure 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

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 CompromisedHyperthermiaHypothermiaImmunization Status, Readiness for Enhanced

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

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

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

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

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

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

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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