review of body systems and preparation of equipment

• The term nursing process was used by Hall (1955), Johnson (1959), Orlando (1961), Wiedenbach (1963), and ANA (1973)
• The nursing process is a systematic, rational method of planning and providing individualized nursing care
• Characteristics of the nursing process:

  • Cyclic and dynamic in nature
  • Client-centered
  • Focus on problem-solving and decision-making
  • Different but parallel to the process used by physicians
  • Interpersonal and collaborative style
  • Universally applicable
  • Uses critical thinking - logic, intuition, and creativity
• Critical thinking in health assessment:

  • Purposeful, goal-directed thinking process
  • Combines logic, intuition, and creativity
  • Clinical reasoning is a disciplined, creative, and reflective approach used with critical thinking
• Components of critical thinking:

  • Interpretation: decode hidden messages, clarify meaning, categorize information
  • Analysis: identify discrepancies and reflect on reasons
  • Inference: speculate, derive, reason based on information and assumptions
  • Explanation: justify conclusions drawn from inferences
  • Evaluation: examine validity of information and hypothesis
  • Self-regulation: reflect on critical thinking skills employed and determine effectiveness
• Types of health assessment in nursing practice:

  1. Initial Comprehensive Assessment

  2. Ongoing or Partial Assessment

  3. Focused or Problem-Oriented Assessment

  4. Emergency Assessment
• Frameworks in health assessment:

  • Functional Health Framework
  • Cephalocaudal Framework
  • Body Systems Framework
• Nurses' role in health assessment:

  • Dynamic factors influencing roles of nurses
  • Role expansion, new roles
  • Computerized information systems
  • Education vs economy: supply vs demand
  • Educational costs and focus on primary care
  • Aging population
  • Mental health issues
  • HMOs
• Nurses in the past relied on their natural senses to observe the client's face and body for changes in color, temperature, muscle strength, use of limbs, body output, and degrees of nutrition and hydration
• Examples of independent nursing practice from 1901 to 1938 include inspection, palpation, and auscultation
• In the 1930s, there was routine client and home inspection by Public Health Nurses (PHN)
• In the 1970s, there was an expansion in the conduct of health histories and physical/psychological assessments
• In the 1980s, acute care nurses employed the "primary care" method of delivery of care
• In the 1990s, critical pathways or care maps were introduced
• In the 21st century, emerging roles impacting health assessment include forensic, acute care, ambulance care, critical care outreach, ambulatory care, home health, public health, school, and hospice
• Interviewing is a method of gathering information from the client and requires professional, interpersonal, and interviewing skills
• The two foci of an interview are establishing rapport and a trusting relationship, and gathering information on the client's status
• Phases of an interview include pre-introductory, introductory, working, and summary and closing
• Non-verbal communication is as important as verbal communication and includes appearance, demeanor, posture, facial expression, and attitude
• Listening is the most important skill to collect complete and valid data from the client
• Verbal communication techniques include open-ended questions, close-ended questions, laundry list, rephrasing, well-placed phrases, inferring, and providing information as questions arise
• Special considerations in health assessment include age, culture, and emotional variations such as dealing with anxious, angry, depressed, manipulative, and seductive clients
• Steps in health assessment include collecting subjective data, components of the health history like biographical data, reasons for seeking healthcare, history of present health concern, personal health history, family health history, and review of body systems
• Personal health history focuses on past medical history from childhood to the present, including childhood illnesses, adult illnesses, surgeries, accidents, allergies, and pregnancies/births
• Family health history includes genetic predisposition, genograms, smoking, and obesity
• Review of body systems involves addressing each body system and eliciting further details of current health problems or recurring issues from the recent past
• Head, neck:

  • Symptoms include headache, swelling, stiffness of the neck, difficulty in swallowing, sore throat, and enlarged lymph nodes
• Eyes:

  • Symptoms include vision issues, infections, redness, excessive tearing, halos around lights, blurring, loss of side vision, black spots/specks in visual fields, flashing lights, double vision, and eye pain
• Ears:

  • Symptoms include hearing problems, ringing or buzzing, earaches, drainage, dizziness, and exposure to loud noises
• Mouth, throat, nose, sinuses:

  • Symptoms include conditions of teeth and gums, sore throats, mouth lesions, hoarseness, rhinorrhea, nasal obstruction, frequent colds, sneezing, itching of eyes, ears, nose or throat, nosebleeds, and snoring
• Thorax, lungs:

  • Symptoms include difficulty breathing, wheezing, pain, shortness of breath during routine activity, orthopnea, cough or sputum, hemoptysis, and respiratory infections
• Breasts, regional lymphatics:

  • Symptoms include lumps or discharge from the nipple, dimpling/changes in breast size, and swollen or tender lymph nodes in the axilla
• Heart, neck vessels:

  • Symptoms include chest pain/pressure, palpitations, edema, and last blood pressure readings
• Peripheral vascular:

  • Symptoms include swelling/edema, pain/cramping, sores on legs, and color/texture changes in legs or feet
• Abdomen:

  • Symptoms include indigestion, difficulty swallowing, nausea, vomiting, abdominal pain, gas, jaundice, and hernias
• Genitalia:

  • Male symptoms include excessive/painful urination, difficulty with urinary stream, leaking urine, blood in urine, sexual problems, penile lesions, penile drainage, pain/swelling in scrotum, difficulty achieving erection/ejaculation, and exposure to STDs
  • Female symptoms include sexual problems, STIs, voiding problems, reproductive data (menstruation details, pregnancies, delivery issues, abortions, pelvic pain, contraception, menopause details)
• Anus, rectum, prostate:

  • Symptoms include bowel habits, pain with defecation, hemorrhoids, blood in stool, constipation, and diarrhea
• Musculoskeletal:

  • Symptoms include swelling, redness, pain, stiffness of joints, ability to perform ADLs, and muscle strength
• Neurologic:

  • Symptoms include mood changes, behavior, depression, anger, concussions, headaches, loss of strength/sensations, coordination issues, difficulty speaking, memory problems, strange thoughts/actions, and difficulty learning
• Healthcare Infection Practices in Physical Examination