PHYSICAL ASSESSMENT Presented by: Pamela Gwin MSN, RN-BC, CNE1
Ideally…..
• Prior to physical assessment:
–Review patient records &
... [Show More] biographic
data
–Review diagnoses and test results as
appropriate
–Obtain needed equipment
–Consult resources PRNAssessment
• Head to Toe- simultaneously
gather subjective & objective
data
• Body Systems Approachclustered findings to more easily
identify problems
3Assessment, cont’d.
• Focused- partial assessment which
focuses on specific complaint or
problem in or r/t a certain area
• Emergency- Assess & prioritize care
according to CABs (circulation, airway,
breathing)
–Rapid assessment = immediate
diagnosis= prompt treatmentNursing Process
• An organized, ongoing, continuous sequence of
problem-solving steps:
– Assessment: systematic collection of facts
– Nursing Diagnosis: identification of actual or
potential problems for which the patient is at risk
– Planning: Identifying goals & interventions
– Implementation or interventions: actual nursing
actions to assist the patient to meet goals
– Evaluation: was the goal met? partially met? not
met?
– Revision: changing the plan
5Purpose
• Assessment data is collected,
organized, and analyzed to make a
clinical nursing judgment/formulate
a nursing diagnoses
• Documentation must be accurate and
descriptive to facilitate data analysis
& result in appropriate conclusionsDiagnostic Reasoning Process
• Step 1-identify abnormal subjective
& objective data
• Step 2-cluster data; identify findings
that are related
• Step 3- draw inferences from data
collectedReasoning Process, cont’d.
• Step 4- propose possible nursing
diagnoses
• Step 5- check defining characteristics
of nursing diagnosis
• Step 6- confirm or rule out diagnosis
• Step 7- document conclusionsNursing Diagnoses
• Actual- patient is currently experiencing
the problem
• Risk for- will likely occur without
intervention
• Wellness- opportunity for enhanced
health
• Collaborative- patient problem that
requires both medical and nursing
interventionsHolism
• A concept that refers to a person’s
physical, emotional, social, and spiritual
health
–Any problem in any of these areas will
have an impact on the others
–Nurses practice holistic medicine:
meaning you work to restore physical,
emotional, social, and spiritual healthGetting Started
• Demonstrate confidence
• Explain what you intend to do
• Be prepared with all equipment, etc.
• Provide privacy, reduce noise, etc.
• Begin with easy to answer openended questions
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