RNSG 1205 Physical Assessment Presentation by Pamela Gwin_Updated

PHYSICAL ASSESSMENT Presented by: Pamela Gwin MSN, RN-BC, CNE1 Ideally….. • Prior to physical assessment: –Review patient records & biographic data –Review diagnoses and test results as appropriate –Obtain needed equipment –Consult resources PRNAssessment • Head to Toe- simultaneously gather subjective & objective data • Body Systems Approachclustered findings to more easily identify problems 3Assessment, cont’d. • Focused- partial assessment which focuses on specific complaint or problem in or r/t a certain area • Emergency- Assess & prioritize care according to CABs (circulation, airway, breathing) –Rapid assessment = immediate diagnosis= prompt treatmentNursing Process • An organized, ongoing, continuous sequence of problem-solving steps: – Assessment: systematic collection of facts – Nursing Diagnosis: identification of actual or potential problems for which the patient is at risk – Planning: Identifying goals & interventions – Implementation or interventions: actual nursing actions to assist the patient to meet goals – Evaluation: was the goal met? partially met? not met? – Revision: changing the plan 5Purpose • Assessment data is collected, organized, and analyzed to make a clinical nursing judgment/formulate a nursing diagnoses • Documentation must be accurate and descriptive to facilitate data analysis & result in appropriate conclusionsDiagnostic Reasoning Process • Step 1-identify abnormal subjective & objective data • Step 2-cluster data; identify findings that are related • Step 3- draw inferences from data collectedReasoning Process, cont’d. • Step 4- propose possible nursing diagnoses • Step 5- check defining characteristics of nursing diagnosis • Step 6- confirm or rule out diagnosis • Step 7- document conclusionsNursing Diagnoses • Actual- patient is currently experiencing the problem • Risk for- will likely occur without intervention • Wellness- opportunity for enhanced health • Collaborative- patient problem that requires both medical and nursing interventionsHolism • A concept that refers to a person’s physical, emotional, social, and spiritual health –Any problem in any of these areas will have an impact on the others –Nurses practice holistic medicine: meaning you work to restore physical, emotional, social, and spiritual healthGetting Started • Demonstrate confidence • Explain what you intend to do • Be prepared with all equipment, etc. • Provide privacy, reduce noise, etc. • Begin with easy to answer openended questions - - - - -