clinical judgment

• systemic method of collecting data

  • determining current, ongoing health status
  • predicting risks
  • identifying health promoting activities
• focus of assessment - problems/deficits presented by client
• data gathered by assessment:

  • wellness behaviours
  • illness signs and symptoms
  • client strengths, weaknesses, and risk factors
  • variety of sources - client, family, support persons
• components of a health assessment

  • general survey
  • sources of data
  • interview
  • physical assessment
  • documentation
  • interpretation of findings
• primary source of data is the client
• secondary sources of data

  • support people
  • client records
  • healthcare professionals
  • literature
• subjective data

  • symptoms or covert data (can't be seen)
  • what client/patient/resident says about stuff
• objective data

  • signs or overt data
  • what you as a nurse finds, assess
  • use IPPA inspect, percuss, palpate, and auscultate
  • read lab values
  • read x-ray and ultra sound results
• types of interview questions

  • closed questions
  • open ended questions
  • neutral questions
  • leading questions
• communication

  • an exchange of information so that each person clearly understands the other
  • it is a skill that we can learn and polish
  • it is a tool we use during the interview
  • it is not just talking and hearing
  • it is all behaviour, conscious and unconscious verbal and non verbal
• health history includes

  • family history
  • personal/social history
  • review of symptoms
  • functional assessment of ADL's
  • biographic data
  • reason for seeking care
  • patient health or history of present illness
  • past medical history
• types of physical examination

  • initial assessment
  • system specific examination
  • examination of a body area
• purpose of examination

  • baseline data about functional abilities
  • supplement, confirm, refute data in history
  • obtain data
  • evaluate outcomes, progress
  • make clinical judgments
  • identify areas for health promotion, disease prevention
• examination positions

  • horizontal recumbent position
  • dorsal recumbent
  • prone
  • fowlers
  • knee chest
  • sims
  • dorsal lithotomy
• comprehensive assessment

  • is usually the initial assessment, it is very thorough and includes a detailed health history and physical examination
  • it examines the clients overall health status
• focused assessment is problem-orientated and may be the initial assessment or an on going assessment
• technical skills used during the physical exam

  • inspection
  • palpation
  • percussion
  • auscultation
• inspection concentrated watching:

  • always comes first
  • compare left and right sides of body
  • requires good lighting and adequate exposure
  • visual examination
  • deliberate, purposeful, systemic
  • naked eye, lighted instruments
• palpation: sense of touch

  • texture
  • swelling
  • temperature
  • pulsation
  • moisture
  • tenderness or pain
  • lumps, and/or mass
  • organ location and site
• percussion

  • tapping the persons skin with short, sharp strokes to assess underlying structures
  • maps out the location and site of an organ
  • signals the density of a structure
  • a structure with relatively more air produces a clear, hollow sound
  • a denser more solid structure produces a muffled thud sound
• direct percussion - sinus tenderness
• indirect percussion - lung percussion
• blunt percussion - organ tenderness
• five types of percussion sounds

  • flatness
  • dullness
  • resonance
  • hyper resonance
  • tympany
• tympany

  • drum like
  • over enclosed air
  • source: air in bowel
• resonance

  • hollow
  • over areas of part air part solid
  • source normal lung tissue
• hyper resonance

  • booming
  • over air
  • source lung with emphysema (hyperinflated)
• dullness

  • thud like
  • over solid tissue
  • source is liver, spleen, heart
• flatness

  • flat
  • over dense tissue
  • source is muscle or bone
• auscultation - listening to sounds within the body
• diaphragm - flat edge best for high pitched sounds, breath, heart, bowel sounds, b/p
• bell - deep hollow cup like shape - best for soft low pitched sounds, extra heart sounds (s3 and s4), murmurs, bruits, b/p
• priority one for nurses

  • airway problems
  • breathing problems
  • cardiac or circulation problems
  • vital signs
  • life threatening lab values
• priority two for nurses

  • changes in mental status
  • untreated medical problems
  • pain
  • urinary elimination problems
• priority three for nurses

  • other health problems that dont fit in one or two, activity, rest, family coping, lack of knowledge
• nursing care

  • always begins with an assessment
  • document findings in medical record
  • based on strong knowledge base
  • application of critical thinking
  • role multifaceted
• the 6 functions of clinical judgement

  1. recognize cues
  2. analyze cues
  3. prioritize hypotheses
  4. generate solutions
  5. take action
  6. evaluate outcomes
• the nursing process

  1. assessment
  2. analysis
  3. planning
  4. implementation
  5. evaulation
• opqrstu

  • o - onset
  • p - provocative, palliative
  • q - quality, quantity
  • r - region, rediation
  • s - severity
  • t - timing, treatment
  • u - understanding
• onset = when did you notice the symptoms