HA NOTES: TYPE OF ASSESSMENT
• Initial comprehensive assessment-Baseline data (first meet)
• Ongoing or Partial Assessment (taking vs every 15 min)
• Focused or Problem-Oriented Assessment
• Emergency Assessment-performed during a life-threatening situation. Do assessment fast. Do not do head-to-
toe assessment.
-FOCUS ON ABC
Immediate Dx is needed to provide prompt treatment
Major and only concern – to determine the status of the client’s life sustaining physical functions
Comparing Subjective and Objective Data
Subjective
-Data elicited and verified by the client
-Sources:
Client
Family and SO
Client record
Other health care professionals
-Methods used to obtain data: Client interview
-Skills needed to obtain data:
Interview and therapeutic communication skills
Caring ability and empathy
Listening skills
examples:
“I have a headache”
“It frightens me”
“I am hungry”
Objective
,-Data directly or indirectly observed through measurement
-Sources:
Documentation of assessment made in client record
-Skills needed to obtain data: IPPA
Observations and PA findings of the nurse or other health care professionals
actions made by family, SO
-Methods used to obtain data: Observation and PE
-examples:
RR = 16 bpm
BP = 180/100
X-ray =
fractured ribs
ELDERLY
HEARING
• Speak slowly
• May be interpreted as mental slowness
• Face client
• Do not yell
• Position- on the side with better hearing
• Speak clearly
• Simple terms
• No slang
INSPECTION
Involves using the senses of vision, smell any
Precedes palpation, percussion and
, auscultation
Use of senses - body senses require special
equipment
GUIDELINES
-Make sure the room is in a comfortable temperature. A too-cold or too-hot room can alter the normal behavior of
the client and the appearance of the client's skin.
-Use good lighting, preferably sunlight overlooked with dim lighting.
-Look and observe before touching.
-Crepitus- grating, crackling popping sound and sensation experienced under the joint skin
-Fremitus- palpable vibration
-examiner’s fingernails should be short and the hands should be a comfortable temperature
STANDARD PRECAUTION- if applicable
Light palpation: (safest) and the most
comfortable to moderate palpation to deep palpation
MODERATE PALPATION: depress the skin surface 1-2 cm with your dominant hand and use a circular motion to
feel for easily palpable body organ and masses
- Note size, consistency and mobility of structures you palpate
DEEP PALPATION: Place your dominant hand on the skin surface and your non-dominant hand on top of your
dominant hand to apply pressure
- Result in surface depression between 2.5-5 cm
- Allows you to feel very deep organics or structures that are covered by thick Muscles
Hand Part and Sensitive To
Finger pads- Fine discriminations, pulses, texture, size, consistency, shape, crepitus
Ulnar or palmar surface- Vibrations, thrills,fremitus
Dorsal (back) surface- Temperature
Percussion
-Involves tapping the body parts to produce sound waves
-These sound waves or vibrations enable the examiner to assess underlying structures uses:
• Initial comprehensive assessment-Baseline data (first meet)
• Ongoing or Partial Assessment (taking vs every 15 min)
• Focused or Problem-Oriented Assessment
• Emergency Assessment-performed during a life-threatening situation. Do assessment fast. Do not do head-to-
toe assessment.
-FOCUS ON ABC
Immediate Dx is needed to provide prompt treatment
Major and only concern – to determine the status of the client’s life sustaining physical functions
Comparing Subjective and Objective Data
Subjective
-Data elicited and verified by the client
-Sources:
Client
Family and SO
Client record
Other health care professionals
-Methods used to obtain data: Client interview
-Skills needed to obtain data:
Interview and therapeutic communication skills
Caring ability and empathy
Listening skills
examples:
“I have a headache”
“It frightens me”
“I am hungry”
Objective
,-Data directly or indirectly observed through measurement
-Sources:
Documentation of assessment made in client record
-Skills needed to obtain data: IPPA
Observations and PA findings of the nurse or other health care professionals
actions made by family, SO
-Methods used to obtain data: Observation and PE
-examples:
RR = 16 bpm
BP = 180/100
X-ray =
fractured ribs
ELDERLY
HEARING
• Speak slowly
• May be interpreted as mental slowness
• Face client
• Do not yell
• Position- on the side with better hearing
• Speak clearly
• Simple terms
• No slang
INSPECTION
Involves using the senses of vision, smell any
Precedes palpation, percussion and
, auscultation
Use of senses - body senses require special
equipment
GUIDELINES
-Make sure the room is in a comfortable temperature. A too-cold or too-hot room can alter the normal behavior of
the client and the appearance of the client's skin.
-Use good lighting, preferably sunlight overlooked with dim lighting.
-Look and observe before touching.
-Crepitus- grating, crackling popping sound and sensation experienced under the joint skin
-Fremitus- palpable vibration
-examiner’s fingernails should be short and the hands should be a comfortable temperature
STANDARD PRECAUTION- if applicable
Light palpation: (safest) and the most
comfortable to moderate palpation to deep palpation
MODERATE PALPATION: depress the skin surface 1-2 cm with your dominant hand and use a circular motion to
feel for easily palpable body organ and masses
- Note size, consistency and mobility of structures you palpate
DEEP PALPATION: Place your dominant hand on the skin surface and your non-dominant hand on top of your
dominant hand to apply pressure
- Result in surface depression between 2.5-5 cm
- Allows you to feel very deep organics or structures that are covered by thick Muscles
Hand Part and Sensitive To
Finger pads- Fine discriminations, pulses, texture, size, consistency, shape, crepitus
Ulnar or palmar surface- Vibrations, thrills,fremitus
Dorsal (back) surface- Temperature
Percussion
-Involves tapping the body parts to produce sound waves
-These sound waves or vibrations enable the examiner to assess underlying structures uses:
