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Assessment
- Collect Data:
- review of the clinical record
- interview
- health history
- physical examination
- functional assessment
- consultation
- review of the literature
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Evaluation
- *Refer to established outcoems
- *Evaluate the individual's condition and compare actual outcomew with expected outcomes
- *Summarize the results of the evaluation
- identify reasons for the person's failure, if indicated, to achieve expected outcomes stated in the plan of care
- *Document evaluation
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Implementation
- *Review the planned intervetions
- *Schedule and coordinate the person's total health care
- *Collaborate with other team members
- *Supervise implementation of the care plan by delegating appropriate responsibilities
- *Counsel the person and significant others
- involve person in the health care
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Planning
- *establish priorities
- *Develop outcomes
- *Set time frames for outcomes
- *identify interventions
- *Document plan of care
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Outcome Identification
- *identify expected outcomes
- *individualize to the person
- *realistic and measurable
- *include a time frame
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Diagnosis
Interpret data: Identify clusters of cues make inferences
- *Validate inferences
- *compare clusters of cues with definition and defining characteristics
- *Identify related factors
- *document the diagnosis
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First level priority problems: ABC
- Airway
- Breathing
- Circulation
- Vital sign concerns
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Second level priority problems
- Mental status changes
- Acute pain
- Acute urinary elimination problems
- Untreated medical problems
- Abnormal lab values
- Risk of infection, safety or security
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Third level priority problems
- Lack of knowledge
- Activity
- Rest
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Assessment Techniques
- Inspection
- Palpation
- Percussion
- Auscultation
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Inspection
- Always comes first
- Begins the moment you first meet the pt (general survey)
- Close and careful scrutiny
- Takes time
- Yields a great amount of data
- Requires good lighting, adequate exposure and use of instruments
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Palpation sense of .....
- Touch to assess...
- Temp
- Moisture
- Organ locations and size
- Vibration or pulsation
- Rigidity or spasticity
- Crepitation
- Presence of pain, lumps, masses
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Palpating with fingers
Fingertips- fine tactile discrimination
*skin texture, swelling, pulsation, presence of lumps
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Palpating by grasping action of fingers and thumb
Detect position, shape, consistency of organ/mass
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Palpating with the base of the fingers/ulnar surface of hand
Best for vibration
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Palpating using the back of hands and fingers
- best for determining temperature
- skin is thinner than palms
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Palpation should be
- Slow and systematic
- Calm and gentle approach
- Warm hands first
- Identify and tender areas and palpate last
- Light palpation
- Deep palpation
- Bimanual palpation
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Percussion
Assess underlying structures
- Tap skin with short, sharp strokes
- Depicts location, size and density of underlying organs
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Yield
palpable vibration and a characteristic sound
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Characteristics of percussion notes
- Resonant
- Hyperresonant
- Tympany
- Dull
- Flat
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Resonance
heard over lung tissue
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Tympany
heard over most portions of the abdominal cavity
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Dullness
heard over solid organs (liver) and muscles
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Abnormal Lung percussion sounds
Dullness- may be produced by pneumonia, tumor, infarction, or fluid collection
Hyperresonance or even tympany, which may result from confluent air collection, as seen in pneumothroax or emphysema
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Abnormal Abdomen Perscussion sounds
Dullness, which may be produced by intra-abdominal tumors or masses;
shifting dullness may indicate presence of ascites
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Abnormal Heart percussion sounds
an expanded area of dullness may indicate cardiomegaly or pericardial effusion
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What can you hear in the Diaphragm of your stethoscope
high pitched sounds: breath, bowel, heart
Use firm pressure
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What can you hear in the Bell of you stethoscope
Soft, low-pitched sounds: extra heart sounds, murmurs
Use light pressure
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Problem- oriented medical records
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What does SOAP stand for
- Subjective
- Objective
- Assessment
- Plan
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