Physical
Assessment
An Overview
J. Carley RN, MSN, MA, CNE
Fall, 2009
You’re Late !
Let’s Start
Report….
Rm. 3A:
Rm. 4A:
Rm. 5A:
Rm. 6A:
Rm. 7A:
Velma Aguon
76 y.o. P.I.-Am. Female
DX: Hypertensive
Crisis
Mike Smithe
32 y.o. Afr-Am Male
Julian Reilly 44 y.o.
Cauc.
Male
DX: Pericarditis
Ashley Wilkes
26 y.o. Cauc.
Female
DX: Mitral Stenosis
Emsley Owens
72 y.o. Afr-Am
Male
DX: CHF
DX:
R/O M.I., HTN
RN’s Comment: “Oh, *&%$#!!!”
“New Admission”
Rm. 8A:
Rm. 9A:
Rm. 10A:
Rm. 11A:
Rm. 12A:
Redd Butler
56 y.o Cauc.
DX: Cardiomyopathy,
CHF
Faith Hopee
78 y.o. N.A.
Female
DX: A- Fib
Frank Arbugast
18 y.o. Afr-Am
Male
Aubrey Embry
38 y.o. J.A.
Female
DX: Endocarditis
Yolanda Zahara
55 y.o. M.E. A.
Female
DX: Sickle-Cell Cr.
DX: Buerger’s Disease
mnemonic
“A-D-O-P-I-E”
Nursing
Process
Assessment
Diagnosis
Outcome
Identification
Planning
Intervention
Evaluation
List of NANDA Nursing Diagnoses
Content and Process
of This Course !
The
Nursing
Process
•
A Closer Look
Assessment
Collect Data:
√ Review the Clinical Record
√ Interview
√ Health History
√ Physical Examination
√ Functional Assessment
√ Consultation
* Review of the Literature
(--Evidence Based Practice)
Diagnosis
*Interpret Data:
√ Identify clusters / cues
√ Make Inferences
* Validate Inferences
* Compare clusters of cues w/ definition,
defining characteristics
* Identify Related Factors
* Document the nursing diagnosis
Outcome Identification
--Identify expected outcomes
--INDIVIDUALIZE to the person
--Realistic and MEASURABLE
--Include a TIME FRAME
Planning
--Establish priorities
--Develop Outcomes
--Set time frames for outcomes
--Identify Interventions
--Document Plan of Care
“The Nursing Care Plan”
Implementation
--Review planned interventions
--Schedule & coordinate patient’s care
--Collaborate w/ other team members
--Supervise implementation by delegation
--Counsel patient & family
--Involve the patient in their care
--Referrals as need for continuity of care
--Document care provided
Evaluation
--Refer to the outcomes you established
--Evaluate individual’s condition: compare
actual outcomes to expected outcomes
--Summarize results of the evaluation
--If expected outcomes not met, identify
reasons
--Modify Plan of Care as necessary
--Document Evaluation of Outcomes, and
changes (if any) in Plan of Care
Nursing Process
Assessment
Diagnosis
Outcome
Identification
Planning
Intervention
mnemonic
“A-D-O-P-I-E”
Evaluation
Subjective Data
Objective Data
Objective Data:
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Blood Pressure = 142 / 98 mm Hg
Weight = 158 lbs (= 71.8 kg)
Oral Intake = 2400 mL / 24 hours
Urinary Output = 250 mL / 24 hours
Imbalance Between Oral Intake &
Urinary Output (above)
The Interview
“Yes.”
“Uh Huh.”
“I see…”
The
Interview
• During the interview, it is a chance for
the patient to tell you how he or she
PERCEIVES what is going on—what
they THINK (or want you to think)
their health state is…
U2: Your Blue Room
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Learning Games
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Part 2:
Interviewing &
Documentation
The Nursing
Interview
“The Nursing Process…”
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Mnemonic: “ADOPIE” = “The Nursing Process”
Assessment
Diagnosis
Evaluation
Outcome
Identification
Implementation
Planning
Establish Rapport
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Get organized
Do not rely on memory
Plan enough time
Ensure privacy
Get focused
Be calm, confident, warm, and helpful
Begin the Interview
• Give your name and
position
• Verify the client’s name
• Briefly explain your
purpose
How to listen
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Be an empathetic listener
Use short supplementary phrases
Listen for feelings as well as words
Let the person know when you see body
language that conflicts with what they
say
• Be patient if the patient has a memory
block
• Avoid the impulse to interrupt
• Allow for pauses
How to ask Questions
• Ask about the main problem first = chief
complaint
• Focus your questions to gain specific
information about the signs and symptoms
• Don’t lead the witness
• Restate the other person’s words to clarify
• Use open-ended questions
• Avoid closed –ended, yes or no questions
How to terminate the interview
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If the session has been long, give a warning
As the person to summarize their primary
concerns
Ask if there are other areas to be discussed
Offer yourself as a resource
Explain routines and provide information
about who does what
End on a positive note
Charting & Documentation
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If it isn’t written, then it wasn’t done
Chart at the time it occurs – if possible
Follow facility guidelines
Is the information clear and logical?
Is it true?
Is it non - judgmental?
Record all abnormals and normals
Charting guidelines
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Be precise
Stick to the facts
Sign your name after each entry
SOAP format – focuses on specific problems
AIR, DAR, PIE, DIE formats – focus on
nursing interventions and client response
Prioritize the client problems
Part Two:
Complete Health History
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Biographical Data
Reasons for Seeking Health Care
History of Present Health Concern
Past Health History
Family Health History
Lifestyle and Health Practices Profile
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Description of Typical Day
Nutrition and Weight Management
Activity Level and Exercise
Sleep and Rest
Medication and Substance Use
Self-Concept
Self-Care Responsibilities
NANDA Nursing Diagnosis List
Activity Intolerance
Activity Intolerance, Risk for
Airway Clearance, Ineffective
Anxiety
Anxiety, Death
Aspiration, Risk for
Attachment, Parent/Infant/Child, Risk for Impaired
Autonomic Dysreflexia
Autonomic Dysreflexia, Risk for
Blood Glucose, Risk for Unstable
Body Image, Disturbed
Body Temperature: Imbalanced,
Risk for
Bowel Incontinence
Breastfeeding, Effective
Breastfeeding, Ineffective
Breastfeeding, Interrupted
Breathing Pattern, Ineffective
Cardiac Output, Decreased
Caregiver Role Strain
Caregiver Role Strain, Risk for
Comfort, Readiness for Enhanced
Communication: Impaired, Verbal
Communication, Readiness for Enhanced
Confusion, Acute
Confusion, Acute, Risk for
Confusion, Chronic
Constipation
Constipation, Perceived
Constipation, Risk for
Contamination
Contamination, Risk for
Coping: Community, Ineffective
Coping: Community, Readiness for Enhanced
Coping, DefensiveCoping: Family, Compromised
Coping: Family, Disabled
Coping: Family, Readiness for Enhanced
Coping (Individual), Readiness for Enhanced
Coping, IneffectiveDecisional Conflict
Decision Making, Readiness for
Enhanced
Denial, Ineffective
Dentition, Impaired
Development: Delayed, Risk
forDiarrhea
Disuse Syndrome, Risk for
Diversional Activity, Deficient
Energy Field, Disturbed
Environmental Interpretation Syndrome, Impaired
Failure to Thrive, Adult
Falls, Risk for
Family Processes, Dysfunctional: Alcoholism
Family Processes, Interrupted
Family Processes, Readiness for Enhanced
FatigueFearFluid Balance, Readiness for Enhanced
Fluid Volume, Deficient
Fluid Volume, Deficient, Risk for
Fluid Volume, Excess
Fluid Volume, Imbalanced, Risk for
Gas Exchange, Impaired
Grieving
Grieving, Complicated
Grieving, Risk for Complicated
Growth, Disproportionate, Risk for
Growth and Development, Delayed
Health Behavior, Risk-Prone
Health Maintenance, Ineffective
Health-Seeking Behaviors (Specify)
Home Maintenance, Impaired
Hope, Readiness for Enhanced
Hopelessness
Human Dignity, Risk for Compromised
Hyperthermia
Hypothermia
Immunization Status, Readiness for Enhanced
Infant Behavior, Disorganized
nfant Behavior: Disorganized, Risk for
Infant Behavior: Organized, Readiness for Enhanced
Infant Feeding Pattern, Ineffective
Infection, Risk for
Injury, Risk for
Insomnia
Intracranial Adaptive Capacity, Decreased
Knowledge, Deficient (Specify)
Knowledge (Specify), Readiness for Enhanced
Latex Allergy Response
Latex Allergy Response, Risk for
Liver Function, Impaired, Risk for
Loneliness, Risk for
Memory, Impaired
Mobility: Bed, Impaired
Mobility: Physical, Impaired
Mobility: Wheelchair, Impaired Moral Distress
Nausea
Neurovascular Dysfunction: Peripheral, Risk for
Noncompliance (Specify)
Nutrition, Imbalanced: Less than Body
Requirements
Nutrition, Imbalanced: More than Body
Requirements
Nutrition, Imbalanced: More than Body
Requirements, Risk for
Nutrition, Readiness for Enhanced
Oral Mucous Membrane, Impaired
Pain, Acute
Pain, Chronic
Parenting, Impaired
Parenting, Readiness for Enhanced
Parenting, Risk for Impaired
Perioperative Positioning Injury, Risk for
Personal Identity, Disturbed
Poisoning, Risk for
Post-Trauma Syndrome
Post-Trauma Syndrome, Risk for
Power, Readiness for Enhanced
Powerlessness
Powerlessness, Risk for
Protection, Ineffective
Rape-Trauma Syndrome
Rape-Trauma Syndrome: Compound Reaction
Rape-Trauma Syndrome: Silent Reaction
Religiosity, Impaired
Religiosity, Readiness for Enhanced
Religiosity, Risk for Impaired
Relocation Stress Syndrome
Relocation Stress Syndrome, Risk for
Role Conflict, Parental
Role Performance, Ineffective
Sedentary Lifestyle
Self-Care, Readiness for Enhanced
Self-Care Deficit: Bathing/Hygiene
Self-Care Deficit: Dressing/Grooming
Self-Care Deficit: Feeding Self-Care Deficit: Toileting
Self-Concept, Readiness for Enhanced
Self-Esteem, Chronic Low
Self-Esteem, Situational Low
Self-Esteem, Risk for Situational Low
Self-Mutilation
Self-Mutilation, Risk for
Sensory Perception, Disturbed
(Specify: Auditory,Gustatory, Kinesthetic, Olfactory Tactile,Visual)
Sexual Dysfunction
Sexuality Pattern, Ineffective
Skin Integrity, Impaired
Skin Integrity, Risk for Impaired
Sleep Deprivation
Sleep, Readiness for Enhanced
Social Interaction, Impaired
Social Isolation
Sorrow, Chronic
Spiritual Distress
Spiritual Distress, Risk for
Spiritual Well-Being, Readiness for Enhanced
Spontaneous Ventilation, Impaired
Stress, Overload
Sudden Infant Death Syndrome, Risk for
Suffocation, Risk for
Suicide, Risk for
Surgical Recovery, Delayed
Swallowing, Impaired
Therapeutic Regimen Management: Community,Ineffective
Therapeutic Regimen Management, Effective
Therapeutic Regimen Management: Family,Ineffective
Therapeutic Regimen Management, Ineffective
Therapeutic Regimen Management, Readiness for Enhanced
Thermoregulation, Ineffective
Thought Processes, Disturbed
Tissue Integrity, Impaired
Tissue Perfusion, Ineffective (Specify:
Cerebral,Cardiopulmonary, Gastrointestinal, Renal)
Tissue Perfusion, Ineffective, Peripheral
Transfer Ability, Impaired
Trauma, Risk for
Unilateral Neglect
Urinary Elimination, Impaired
Urinary Elimination, Readiness for Enhanced
Urinary Incontinence, Functional
Urinary Incontinence, Overflow
Urinary Incontinence, Reflex
Urinary Incontinence, Stress
Urinary Incontinence, Total
Urinary Incontinence, Urge
Urinary Incontinence, Risk for Urge Urinary Retention
Ventilatory Weaning Response, Dysfunctional
Violence: Other-Directed, Risk for
Violence: Self-Directed, Risk for
Walking, Impaired
Wandering
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