What kind of assessment we do for certain patients:
-Complete: includes health history and physical exam
During assessment we are collecting data, reviewing health history, clinical records,looking
for cues, risk assessment, functional assessment, documenting findings
● Health history the purpose of obtaining a health history is to gather subjective data from the patient
and or the patients family so that the health care team and the patient can collaboratively create a plan
that will promote health, address acute health problems, and minimize chronic health conditions. It also
contains objective data that the health care professionals gather during a physical examination and
consists of information that can be seen felt smelled or heard by the health care professional. Taken
together the data collected provides a health history that gives the health care professional and
opportunity to assess health promotion practices and offer patient education.
● full physical exam - Purpose - obtain baseline data, id nursing diagnosis,PC’s,
Screening, monitor status of already identified problems
● Assesment skills : IPPA(O) Inspection,First, look at the individual as a whole Second, look at each body
.
system.Need good lighting, exposure, & occasional use of instruments
● Palpatation dorsal of hand for temp. Sense of touch.Slow, systematic, calm, and gentle.Light palpation to
deep palpation (intermittent, avoid injury)
● Percussion,Nondominant hand: hyperextend the middle finger, place its distal joint and tip firmly against
the person’s skin. Lift the rest of the stationary hand up off the person’s skin.
● Dominant hand: use the middle finger as the striking finger. Action is on the wrist and must be relaxed.
Bounce your middle finger off the stationary finger. The goal is to hit the portion of the finger that is pushing
the hardest into the skin surface. The tip of the striking finger makes contact
● Aim for just behind the nail bed or at the distal interphalangeal joint
● Percuss 2x in one location and move on.
● Air-filled location: low, deep, long sounds
● Solid location: high, soft, short sounds
● Auscultation Listening to sounds produced by the body with the use of a
stethoscope.Diaphragm – best of high-pitched sounds. breath, bowel, & normal heart sounds. Bell –
best for soft-pitched sounds.extra heart sounds or murmur
● Begins with General Survey : Appearance, Behavior, Body type/Posture, Hygiene, Dress,
Grooming, Mental Status (Orientated x4 vs Orientated x3 Disoriented to Place), VItals
including Pain, Height, Weight BMI
● After General Survey is Assessment of All Body Systems
,● primary care setting
● first admission
● first time entering the hospital
, -Focused or Problem-Centered
● One problem, cue complex, or body system
● after surgery w/ c/o SOB, outpatient clinic limited to a skin problem
● small settings
● urgent cares
-Follow-Up
● Evaluating the identified problems at regular or appropriate intervals
● meant to note any changes that have occurred overtime in relation to ailments or medication.
The status of any identified problems are evaluated at regular and appropriate intervals. We
are asking questions such as,
● What change has occurred? Is the problem getting better or worse? Hoping strategies are
being used? This type of data is used in all settings to follow up both short term and chronic
health problems.
●
-Emergency
● Urgent, rapid collection of information
● This is an urgent and rapid collection of crucial information and often is compiled concurrently
with lifesaving measures. For example you will not be asking a pt about their family’s health
history if they are reporting difficulty breathing. The focus is on the immediate threats to life.
Always reassessing their vitals and their immediate needs. With airway, breathing, circulation
and mental status as primary….As well as their level of consciousness. After the person has
been stabilized a complete database may be compiled.
● drug overdose “what did you take?” “When?” How Much
● Airway, breathing, circulation, LOC -& disability are assessed
What subjective versus objective data are
Objective data: Is this something that I can sense by using my 5 senses?
• Vital signs
• Blood Pressure
• Pulse Ox
• Heart Rate
• Respirations
• Wounds
• Ambulation
• Skin Temperature, Color, Cool/Dyaphoretic vs Dry/Warm,Turgor
• Capillary Refill
• Pupil dilation/reaction to light
• Smell : Sweet breathe indication of Diabetes
• facial expressions grimacing,
• body language Guarding abdomen area
• signs of abuse or neglect in elderly and children
• Even facial features
Subjective data: Is this something that the patient is feeling or telling me?
• Pain - How do we assess for pain during an interview : rate the pain from 0-10
PQRSTU- Provocation, Quality, Radiation/Region,Severity, Onset/Timing, Understanding
-Complete: includes health history and physical exam
During assessment we are collecting data, reviewing health history, clinical records,looking
for cues, risk assessment, functional assessment, documenting findings
● Health history the purpose of obtaining a health history is to gather subjective data from the patient
and or the patients family so that the health care team and the patient can collaboratively create a plan
that will promote health, address acute health problems, and minimize chronic health conditions. It also
contains objective data that the health care professionals gather during a physical examination and
consists of information that can be seen felt smelled or heard by the health care professional. Taken
together the data collected provides a health history that gives the health care professional and
opportunity to assess health promotion practices and offer patient education.
● full physical exam - Purpose - obtain baseline data, id nursing diagnosis,PC’s,
Screening, monitor status of already identified problems
● Assesment skills : IPPA(O) Inspection,First, look at the individual as a whole Second, look at each body
.
system.Need good lighting, exposure, & occasional use of instruments
● Palpatation dorsal of hand for temp. Sense of touch.Slow, systematic, calm, and gentle.Light palpation to
deep palpation (intermittent, avoid injury)
● Percussion,Nondominant hand: hyperextend the middle finger, place its distal joint and tip firmly against
the person’s skin. Lift the rest of the stationary hand up off the person’s skin.
● Dominant hand: use the middle finger as the striking finger. Action is on the wrist and must be relaxed.
Bounce your middle finger off the stationary finger. The goal is to hit the portion of the finger that is pushing
the hardest into the skin surface. The tip of the striking finger makes contact
● Aim for just behind the nail bed or at the distal interphalangeal joint
● Percuss 2x in one location and move on.
● Air-filled location: low, deep, long sounds
● Solid location: high, soft, short sounds
● Auscultation Listening to sounds produced by the body with the use of a
stethoscope.Diaphragm – best of high-pitched sounds. breath, bowel, & normal heart sounds. Bell –
best for soft-pitched sounds.extra heart sounds or murmur
● Begins with General Survey : Appearance, Behavior, Body type/Posture, Hygiene, Dress,
Grooming, Mental Status (Orientated x4 vs Orientated x3 Disoriented to Place), VItals
including Pain, Height, Weight BMI
● After General Survey is Assessment of All Body Systems
,● primary care setting
● first admission
● first time entering the hospital
, -Focused or Problem-Centered
● One problem, cue complex, or body system
● after surgery w/ c/o SOB, outpatient clinic limited to a skin problem
● small settings
● urgent cares
-Follow-Up
● Evaluating the identified problems at regular or appropriate intervals
● meant to note any changes that have occurred overtime in relation to ailments or medication.
The status of any identified problems are evaluated at regular and appropriate intervals. We
are asking questions such as,
● What change has occurred? Is the problem getting better or worse? Hoping strategies are
being used? This type of data is used in all settings to follow up both short term and chronic
health problems.
●
-Emergency
● Urgent, rapid collection of information
● This is an urgent and rapid collection of crucial information and often is compiled concurrently
with lifesaving measures. For example you will not be asking a pt about their family’s health
history if they are reporting difficulty breathing. The focus is on the immediate threats to life.
Always reassessing their vitals and their immediate needs. With airway, breathing, circulation
and mental status as primary….As well as their level of consciousness. After the person has
been stabilized a complete database may be compiled.
● drug overdose “what did you take?” “When?” How Much
● Airway, breathing, circulation, LOC -& disability are assessed
What subjective versus objective data are
Objective data: Is this something that I can sense by using my 5 senses?
• Vital signs
• Blood Pressure
• Pulse Ox
• Heart Rate
• Respirations
• Wounds
• Ambulation
• Skin Temperature, Color, Cool/Dyaphoretic vs Dry/Warm,Turgor
• Capillary Refill
• Pupil dilation/reaction to light
• Smell : Sweet breathe indication of Diabetes
• facial expressions grimacing,
• body language Guarding abdomen area
• signs of abuse or neglect in elderly and children
• Even facial features
Subjective data: Is this something that the patient is feeling or telling me?
• Pain - How do we assess for pain during an interview : rate the pain from 0-10
PQRSTU- Provocation, Quality, Radiation/Region,Severity, Onset/Timing, Understanding
