H.A. lec midterms

• Nursing Process


  A systematic, rational method of planning that guides all nursing actions in delivering holistic and patient focused care
• Phases of the Nursing Process

  1. Assessment

  2. Diagnoses

  3. Planning

  4. Implementation

  5. Evaluation
• Assessment


  Collecting subjective and objective data
• Subjective data


  Elicited and verified only by the client
• Objective data


  Obtained by general observation by the examiner
• Skills needed to obtain subjective data


  • Interview and therapeutic communication skills
  • Caring ability and empathy
  • Listening skills
• Skills needed to obtain objective data

  • Inspection
  • Palpation
  • Percussion
  • Auscultation
• Diagnosis


  Analyzing subjective and objective data to make and prioritize professional clinical judgement
• Planning


  Generating solutions, developing & plan
• Implementation


  Taking action, Prioritizing and implementing the planning interventions
• Evaluation


  Assess whether outcomes have been met and revising the plan if the interventions did not make a difference
• Nursing Assessment is the most critical phase of the nursing process
• If data collection is inadequate or inaccurate, incorrect clinical judgements may be made that adversely affect the remaining phases of the process
• Holistic Nursing Assessment


  Comprehensive data collection to determine the clients over-all level of functioning in order to make a
• Physical Medical Assessment


  It focuses primarily on the clients physiological status
• Types of Health Assessment

  • Initial comprehensive Assessment
  • Ongoing or partial Assessment
  • Focus/Problem Oriented
  • Emergency Assessment
• Initial Comprehensive Assessment


  -It involves collection of subjective data about the clients perception of the, to establish baseline data against which future health status changes can be measured and compared.

  -Total Health Assessment
• Ongoing or Partial Assessment


  It consists of data collection that occurs after the Initial assessment, consisting of a mining everview of the clients body systems and follow up on health status
• Focused or problem-oriented assessment


  It consists of thorough assessment of a particular client problem and does not address areas not related
• Emergency Assessment

  It is a rapid and immediate assessment performed in life-threatening situations to provide prompt asses treatment
• Steps of Health Assessment

  1. Collecting of subjective data

  2. Collecting objective data

  3. Validation of data

  4. Documentation of data
• Subjective data


  Sensations or symptoms, perceptions, desires, preferences, beliefs, values, etc. that can be elicited and verified only by the client
• Objective data


  Can be directly observed by the examiner
• Validating data


  It helps ensure that all relevant data have been collected and helps to prevent documentation of inaccurate data
• Documenting data


  It is an important step of assessment because it performs and provides process for all other members of the health care team
• Phases of the Interview

  1. Preintroduce Phase (review of patients data)

  2. Introductory Phase (state name and purpose)

  3. Working Phase (interview proper)

  4. Summary or closing Phase (summarize data gathered and get validation)
• Types of Communication


  • Nonverbal (Appearance, Demeanor, Facial expression, Attitude, Silence, Listening)
  • Verbal (Open-ended questions, Close-ended questions, Laundry list, Rephrasing, Inferring, Providing information)
• Sections of Health History


  • Biographical Data
  • Reasons for seeking health care
  • History of Present Health Concern
  • Lifestyle and health practices
  • Personal Health history
  • Family Health history
  • Developmental Level
  • Review of Systems For Current health concerns
  • Lifestyle and Health Practices Profile
• COLD SPA and PQRST analysis

  1. C- Character, O- Onset, L- Location, D- Duration, S- Severity, P- Pattern, A- Associated factors / how it affects the client,
  2. P- Palliative/Provocative, Q- Quality, R- Radiates, S- Severity, T- Timing
• Equipment for Assessment


  • Gloves, gown, Sphygmomanometer & Stethoscope, Thermometer's, watch, with second hand, pain scale rating, pulse oximeter
• Standard Precautions

  Hand hygiene, Gloves, Respiratory hygiene and cough etiquette, Skin and nail care, Proper disposal of sharp objects
• Client Positions

  • Sitting position, Supine position, Dorsal recumbent position, Sims position, Standing position, Knee - Chest postion, Lithotomy Position
• Physical Examination Techniques

  • Inspection
  • Palpation
  • Percussion
  • Auscultation
• Inspection


  Using the senses of vision, smell and hearing to observe and detect any normal or abnormal findings
• Palpation


  Using one's hand or fingers to physically examine part of the body to determine texture, temperature, moisture, mobility, consistency, size, shape, strength of pulses, degree of tenderness
• Parts of Hands when Palpating

  • Fingerpads, Ulnar or Palmar Surface, Dorsal (back) surface
• Types of Palpation

  • Light, Moderate, Deep, Bimanual
• Percussion


  Tapping body parts to produce sound waves which enables the examiner to assess underlying structures
• Types of Percussion

  • Direct, Blunt, Indirect
• Auscultation


  Using a stethoscope to listen for heart sounds, movement of blood through the body