Introduction Physical Examination

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Introduction PhysicalExamination

• Health Assessment

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Why do I need to know Physical Assessment?
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(No Transcript)
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What is your reason for coming here today?
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Assessment

• Collection of data about an individuals health
  state.

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• Subjective Data
• Client history
• Objective Data
• Inspection
• Percussion
• Palpation
• Auscultation

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Data Base

• All the information obj., subjective, clients
  record, lab, and test results
• Study and cluster data
• Diagnosis
• Purpose of assessment is to make a diagnosis or
  judgement

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Nursing Process

• ADPIE
• Assessment
• Diagnosis
• (outcome identification)
• Planning
• Implementation
• Evaluation

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Critical Thinking

• Problem solving the puzzle the big picture
• Processing information use theory learned,
  experience, intuition, intellectual and manual
  skills

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Priority Setting

• First level problems
• ABCs
• Vital Signs
• Second Level
• Mental Status changes (LOC)
• Acute pain
• Acute urinary elimination
• Untreated medical problems
• Abn. Bld. Values
• Risks of infection, safety, security

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• Third Level Priority
• Knowledge deficit
• Activity, rest
• Coping

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4 Types of Data Base

1. Complete ( Total )
2. Episodic or Problem Centered
3. Follow up
4. Emergency

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Consideration of

• Developmental States
• Cultural Assessment
• Beliefs, values, practices

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The Interview

• Spend more time listening
• Open /Closed ended questions
• Interpreter
• Family/ professional

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Communication Skills

• Collecting information with understanding
• Verbal/Nonverbal

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Factors that impact on Communication

• Internal
• Personal attributes acceptance of client
  (Nonjudgemental)
• Respect
• Empathy
• Listening

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Factors that impact on Communication

• External Factors
• Privacy
• Interruptions
• Comfortable environment temp., noise, lunch,
  bloody mess

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10 Traps of Inteviewing pg 57

1. False Assurance
2. Unwanted Advice
3. Using Authority
4. Avoidance language dead is dead
5. Engaging in distance the Friend
6. Professional jargon
7. Leading or biased questions you dont?

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1. Too much talking
2. Interrupting
3. Why?

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Threat of Violence!!!!

• CPI training