NSE 103 Finals

• NSE 103: HEALTH ASSESSMENT
• Describe the assessment phase of the nursing process

  
• Describe related legislation specific to health assessment
• Describe clinical judgment and priorities of care in relation to health assessment

  
• Describe the guiding approaches to health assessment
• Describe the development and concepts of health promotion and its use as a guide to nursing assessment

  
• Describe health promotion interventions, education, and counseling
• Outline the components of a primary survey (airway, breathing, circulation, disability, exposure) and how to combine with a body systems approach
• Apply the components of a mental status examination
• Describe the use of and practice the following physical examination techniques: Inspection, Palpation, Percussion, and Auscultation
• Describe how to ensure the best setting and approach for assessment and practice with the proper use of equipment
• Provide feedback to the client in an informative and respectful manner
• Understand Maslowʼs Hierarchy of Needs in relation to health assessment
• Bradycardia


  Slow heart rate
• Tachycardia


  Fast heart rate
• Sinus arrhythmia


  Irregular heart rhythm
• Clinical judgement


  The observed outcome of critical thinking and decision making, iterative process using knowledge to observe and assess presenting situations, identify a prioritized client concern, and generate the best possible evidence based solutions in order to deliver safe client care

  
• Priorities of care


  • Actions that are most important to take first
  • Actions that can follow
• Primary survey


  Airway, breathing, circulation, disability, exposure (ABCDE) - helps recognize clinical deterioration and trigger clinically indicated focused assessments of body systems
• Levels of consciousness


  • Alert and oriented
  • Confused and disoriented
  • Lethargic
  • Obtunded
  • Unconscious
• Level of orientation


  Place, time, person, self
• Components of mental status examination

  • Appearance
  • Behaviour
  • Cognition
  • Thinking

  
• Intervention (action) types

  • Effective
  • Ineffective
  • Unrelated
  • Contraindicated
• Guiding approaches of health assessment


  • Primary care
  • Long term care
  • Acute care
• Health assessment types


  • Primary survey
  • Focused assessment
  • Head to toe (physical)
  • Complete health assessment
• Health promotion


  Social and environmental interventions to enable people and communities to increase control over health
• Broad approaches to health promotion

  • Behavioural
  • Relational
  • Structural
• Health determinants
• Objective assessment: observe and measure, identify normal and abnormal findings
• Recognizing abnormal cues, acting on abnormal cues
• Trauma informed approach: physical touch, trauma
• Preparing for the objective assessment: bathroom, prepare the environment, privacy and warmth, body positioning and mechanics, developmental considerations, care partners (always perform assessment on bare skin)
• Infection prevention and control
• Anatomical locations (do the readings)
• Use of your own hands, the anatomical positions, anatomical reference points
• Inspection


  Purposeful and systematic, bilateral comparison, client overall and then, specific body areas
• Palpation


  Using your hands/fingers, permission to touch, bilateral comparison

  
• Temperature


  Degree of heat or cold an object holds
• Use dorsal surfaces of your own hands (i.e. the back of the hands), to assess temperature of a skin surface (e.g: skin)
• Percussion


  Indirect percussion technique: non dominant hand, dominant hand