Nursing Practice

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Health Assessment

components

Objective

Urine output

sediment

colour

bloody urine

quantity

O2 saturation

respiratory rates

temperature

blood pressure

Vital Signs

Subjective

experience

Pain levels

physical assessment

changing health status, management

Activities of daily living

dressing

toileting

bathing

Vital signs

Range of motion

Gather baseline data

General Survey

Measurements

Waist to hip ratio

Arm span

BMI

height

weight

Behaviour

personal hygiene

dress

speech

mood

facial expression

Mobility

range of motion

gait

walking

Body structure

symmetry

stature

Physical appearance

facial expressions

skin colour

sexual development

Level of conscieness

age

Confirm and identify nursing diagnoses

Symtoms

not observable to others

perceived or experienced by the patient

sensation or emotion

How it feels

signs

Obseved by others

What you see

Therapeutic Relationship

influences on health care and health care policy

Changes in the health care system such as accessibility, resources, etc

How the health care professional functions

The client’s expectations of the health care system

Awareness of boundaries & limits of professional role

Reflection

recognize boundary violations

keeping secrets with clients

spending extra time with clients

having special clients

client’s best interest

health/illness

Knowledge of best practices

Standard interventions and issues of rehabilitation

symptoms

biological, psychological and/or socio-contextual

the person

Knowledge of person

Self Awareness

Subjective thoughts, feelings, actions

Empathy

Validate that his/her understanding of the client’s experience

attend to the subjective experience

Self knowledge

development

to act purposefully

recognize own experience is shaped by several factors

beliefs

accomplishments

Early childhood experience

education

gender

socio economic conditions

Health

Culture

Nationality

Race

is the

Nursing Practice

Professionalism

ethics

dilemma

conflict

values

should and should not do

professional approach

honest relationships

open relationships

respectful relationships

Techniques

Olfaction

odours

feces

body odour

urine

Alcohol

Percussion

techniques

direct

indirect

sound

percussion notes

density

size

location

fingertips to produce a vibration

Ausculations

sounds

duration

quality

loudness

frequency

stethoscope

normal sounds vs abnormal

concentration and practice

Palpation

ends with deep palpation

light palpation

distinguish texture, temperature, and movement

tenderness, distension, masses

Tender areas are palpated last

uses hands

should be warm

fingernails should be short

Inspection

surfaces can be viewed

compare to opposite side

Recognizes normal and abnormal

Vision, hearing, smell

Observation

Documentation

accountability & responsibility

for self & others

Evaluation

influences

evaluates patient response

Implementation

actions taken relevant to problem

Planning

plan of care

Assessment

objective and subjective data

patient history

current

cheif complaint

day of addmission

past

prior hospitalizations

injuries

surgeries

allergies

communication of clinical information