Transcript Physical Examination

Introduction
Physical
Examination
Health
Assessment
Why do I need to
know Physical
Assessment?
“What is your
reason for coming
here today?”
Assessment
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Collection of data about an individual’s
health state.
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Subjective Data
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Client history
Objective Data
Inspection
 Percussion
 Palpation
 Auscultation
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Data Base
All the information; obj., subjective,
client’s record, lab, and test results
 Study and cluster data
 Diagnosis
 Purpose of assessment is to make a
diagnosis or judgement
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Nursing Process
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ADPIE
Assessment
 Diagnosis
 (outcome identification)
 Planning
 Implementation
 Evaluation
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Critical Thinking
Problem solving – the puzzle – the big
picture
 Processing information – use theory
learned, experience, intuition,
intellectual and manual skills
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Priority Setting
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First level problems
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ABC’s
Vital Signs
Second Level
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Mental Status changes (LOC)
Acute pain
Acute urinary elimination
Untreated medical problems
Abn. Bld. Values
Risks of infection, safety, security
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Third Level Priority
Knowledge deficit
 Activity, rest
 Coping
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4 Types of Data Base
1.
2.
3.
4.
Complete ( Total )
Episodic or Problem Centered
Follow – up
Emergency
Consideration of:
Developmental States
 Cultural Assessment
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Beliefs, values, practices
The Interview
“Spend more time listening”
 Open /Closed ended questions
 Interpreter
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Family/ professional
Communication Skills
Collecting information with
understanding
 Verbal/Nonverbal
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Factors that impact on
Communication
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Internal
Personal attributes – acceptance of client
(Nonjudgemental)
 Respect
 Empathy
 Listening
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Factors that impact on
Communication
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External Factors
Privacy
 Interruptions
 Comfortable environment – temp., noise,
lunch, bloody mess
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10 Traps of Inteviewing pg 57
1.
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6.
7.
False Assurance
Unwanted Advice
Using Authority
Avoidance language – dead is dead
Engaging in distance “the Friend”
Professional jargon
Leading or biased questions; “you don’t…?”
8.
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10.
Too much talking
Interrupting
Why?
Threat of Violence!!!!
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CPI training