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Introduction Physical Examination

Introduction Physical Examination. Health Assessment. Why do I need to know Physical Assessment?. “What is your reason for coming here today?”. Assessment. Collection of data about an individual’s health state. Subjective Data Client history Objective Data Inspection Percussion

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Introduction Physical Examination

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  1. Introduction PhysicalExamination Health Assessment

  2. Why do I need to know Physical Assessment?

  3. “What is your reason for coming here today?”

  4. Assessment • Collection of data about an individual’s health state.

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

  6. Data Base • All the information; obj., subjective, client’s record, lab, and test results • Study and cluster data • Diagnosis • Purpose of assessment is to make a diagnosis or judgement

  7. Nursing Process • ADPIE • Assessment • Diagnosis • (outcome identification) • Planning • Implementation • Evaluation

  8. Critical Thinking • Problem solving – the puzzle – the big picture • Processing information – use theory learned, experience, intuition, intellectual and manual skills

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

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

  11. 4 Types of Data Base • Complete ( Total ) • Episodic or Problem Centered • Follow – up • Emergency

  12. Consideration of: • Developmental States • Cultural Assessment • Beliefs, values, practices

  13. The Interview • “Spend more time listening” • Open /Closed ended questions • Interpreter • Family/ professional

  14. Communication Skills • Collecting information with understanding • Verbal/Nonverbal

  15. Factors that impact on Communication • Internal • Personal attributes – acceptance of client (Nonjudgemental) • Respect • Empathy • Listening

  16. Factors that impact on Communication • External Factors • Privacy • Interruptions • Comfortable environment – temp., noise, lunch, bloody mess

  17. 10 Traps of Inteviewing pg 57 • False Assurance • Unwanted Advice • Using Authority • Avoidance language – dead is dead • Engaging in distance “the Friend” • Professional jargon • Leading or biased questions; “you don’t…?”

  18. Too much talking • Interrupting • Why?

  19. Threat of Violence!!!! • CPI training

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