NUR 2180 Physical Assessment Module 1 Subjective Information - What the client tells you Objective Information - What you measure or observe Open Ended Questions - Allows for the collection for more information for the client to elaborate on their symptoms or concerns.Closed Ended Questions - Allows for a yes or no answer only Genogram - Method of visually portraying family relationships and medical history to see trends Therapeutic Communication - a way to communicate with patients and staff while respecting values Databases - helps us assess, track, see labs and notes, and give medications. allows nurses to make clinical judgments and be organized Cultural Competency - respecting all areas of culture and respecting values of patients specific to culture Steps of the Nursing Process - Assessment Diagnosis Outcome Identification Planning Implementation Evaluation Assessment - Collecting data from medical record, health history, physical exam, functional assessment, risk assessment while using evidence based practice Diagnosis - Compare clinical findings with normal and abnormal variations and developmental events. interpret data and create hypothesis and nursing diagnosis Outcome Identification - Identify expected outcomes, individualize to the person, culturally appropriate, realistic and measurable, include a timeline Planning - Establish priorities, develop outcomes, set timelines for outcomes, identify interventions, integrate evidence based practice Implementation - Must be done in a safe and timely manner using evidence based practice. Coordinate care and collaborate with other while giving treatment.Evaluation - Progress towards outcomes. Must be systemic and ongoing. Can be revised and must include patient and family. 1 / 2
Novice Nurse - Starting out in an area of learning and using rules to guide practice Competent Nurse - Building on 2-3 years clinical experiences. Actions embeded in context of patient goals or plans.Proficient Nurse - Adding to time and experience. Understands the patient situation as a whole rather than in parts. Applies long term goals Expert Nurse - Attained mastery of an area of learning. Performs clinical judgement using intuitive analysis First Level priority - Emergent, life threatening, and immediate Second Level priority - Next in urgency, requiring attention so as to avoid further deterioration Third Level priority - Important to patient's health but can be addressed after more urgent problems are addressed Collaborative problems - approach to treatment involves multiple disciplines Evidence Based practice - Integration of research evidence, clinical expertise, clinical knowledge, and patient values and preferences. Allows for clinical decision making for best outcome Holistic Nursing Model - Incorporation of impact of external and interpersonal environment on one's mind and body Health Interview - Best chance to gain understanding of the patient as a whole and to collect subjective and objective data Successful Interview Characteristics - Gather complete and accurate data about person's health state including description and chronology of any symptoms.Establish trust to foster acceptance and allow for data sharing.Teach the person about their individual health state.Build rapport to continue therapeutic relationship.Discuss health promotion and disease prevention.Location of Interview - Time and place with follow-up for physical exam Explanation of Interview - Introduction and delineation of role Purpose of Interview - Mutual goal is optimal health.Time frame of Interview - Length of time for process
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