NURSING ASSESMENT

KEY TERM
Assesment Auscultation Data clustering Data collection Data documentation Data sorting Health care team Health story Inspection Interview

Medical record Nursing health story Nursing process Objective data Palpation Percussion Physical examination Subjective data Validation

DATA COLLECTION INVOLVES:

Nursing health history Physical examination Result of laboratory and diagnostic test Information from health care team Familly and significant others

THREE PHASE OF INTERVIEWING

Orientation Working Termination

BASIC COMPONENT OF THE NURSING HEALTH HISTORY

Biographycal and demographycal information Clients reason for seeking health care Client expectations of health care providers Past health status Familly history Environmental history Psychosocial history Present health status and review of symptoms

ASSESSING

Nursing History Nursing examinations Assessment data are documented :

Accurately : questionable data are validated Completely : Use of a systematic giede ensures that recorded data discribe

The clients functional ability to meet ech basic human need Responses to health and illness

Conciesely : Irrelevant data and meaningless generalizations are avoided Factually : Client behaviors are recorded rather than the nurses interpretation of these bahaviour

Focused assesment data are recorded for each client problem

For efficiency, the nurse should use a branching technique during each phase of data collection In Branching the nurse further assesses areas in wich a dysfunction or abnormality appears to exist and abbreviates the assessment in areas in wich no problem is apparent

ASSESMENT CONSIST OF

Assesing Nursing/Ilness history :

Patients identity Chief complaint HPI (History of Present Illness) PNH (Past Nursing History) Familly History

Observation Vital Signs :

T_P_R_BP(Temperature-Pulse-Respirations-Blood Pressure) General Appearance

PE (Physical Examination)

B1-B6 Through Approach of IPPA (Inspection, Percussion,Palpation,Auscultation) Blood Urine Stool X-Ray CT-SCAN etc

Result of Diagnostic Test :

UNDERSTANDING SIGN AND SYMPTOMS

Sign

Something that nurse can see or feel for her self We can observe it Bruising, Rash, swelling, weight loss

Symptom
Something that only the patient knows about The patient tells the nurse about it Nausea, insomnia, all kind of patient

Bruising (bruise) an injury wich makes a mark on the skin (blue or black)but does not break the skin Rash : red spots on the skin. A sign of certain illness such as measles Swelling a part of body wich has become enlarge by diseases or injury e.g a sprained ankle Nausea : feeling sick or wanting to vomit Insomnia :inability to sleep Irregular pulse or respiration : the pulse or respiration rate varies from fast to slow Dizziness,vertigo : the felling that everything is turning aroud you Haematemesis: blood in the vomit Pallor : lack of color in the skin Diarrhea: frequent loose stool, passed through the bowels

Jaundice : the skin and eyes of a patient with jaundice look yellow Dyspnoe : difficulty inbreathing Constipation: when a patient can not open his bowels, or only with difficulty, he has constipation Cyanosis : blue skin caused by insufficient oxygen in the blood Anorexia : lack of appetite Laceration : a cut with broken edges Abration rubbed or torn skin Inflamation : a red, hot, swollen, painfull place on the skin Shallow pulse or respiration a light, faint pulse Respiration : breathing Oedema : swelling caused by excessive fluid in tissues

WHICH IS SIGN AND SYMPTOM

Irregular pulse Dull pain Stomachache Dizziness Haematemesis Hungry Pallor Diarrhea Jaundice Thirst Dypsnea Constipation Headache Cyanosis Anorexia

Laceration Abrasion Inflammation Shallow pulse Weight gain Shallow respiration Backache

The idea is that you have to WIN and be nonviolent You've got to be nonviolent - and you've got to win with nonviolence. " ... Cesar Chavez