Assessment tools and tech

  1. Assessment
    • Collect Data:
    • review of the clinical record
    • interview
    • health history
    • physical examination
    • functional assessment
    • consultation
    • review of the literature
  2. 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
  3. 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
  4. Planning
    • *establish priorities
    • *Develop outcomes
    • *Set time frames for outcomes
    • *identify interventions
    • *Document plan of care
  5. Outcome Identification
    • *identify expected outcomes
    • *individualize to the person
    • *realistic and measurable
    • *include a time frame
  6. 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
  7. First level priority problems: ABC
    • Airway
    • Breathing
    • Circulation
    • Vital sign concerns
  8. 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
  9. Third level priority problems
    • Lack of knowledge
    • Activity
    • Rest
  10. Assessment Techniques
    • Inspection
    • Palpation
    • Percussion
    • Auscultation
  11. 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
  12. Palpation sense of .....
    • Touch to assess...
    • Temp
    • Moisture
    • Organ locations and size
    • Vibration or pulsation
    • Rigidity or spasticity
    • Crepitation
    • Presence of pain, lumps, masses
  13. Palpating with fingers
    Fingertips- fine tactile discrimination

    *skin texture, swelling, pulsation, presence of lumps
  14. Palpating by grasping action of fingers and thumb
    Detect position, shape, consistency of organ/mass
  15. Palpating with the base of the fingers/ulnar surface of hand
    Best for vibration
  16. Palpating using the back of hands and fingers
    • best for determining temperature
    • skin is thinner than palms
  17. 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
  18. Percussion
    Assess underlying structures

    • Tap skin with short, sharp strokes
    • Depicts location, size and density of underlying organs
  19. Yield
    palpable vibration and a characteristic sound
  20. Characteristics of percussion notes
    • Resonant
    • Hyperresonant
    • Tympany
    • Dull
    • Flat
  21. Normal percussion sounds
    • Resonance
    • Tympany
    • Dullness
  22. Resonance
    heard over lung tissue
  23. Tympany
    heard over most portions of the abdominal cavity
  24. Dullness
    heard over solid organs (liver) and muscles
  25. 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
  26. Abnormal Abdomen Perscussion sounds
    Dullness, which may be produced by intra-abdominal tumors or masses;

    shifting dullness may indicate presence of ascites
  27. Abnormal Heart percussion sounds
    an expanded area of dullness may indicate cardiomegaly or pericardial effusion
  28. What can you hear in the Diaphragm of your stethoscope
    high pitched sounds: breath, bowel, heart

    Use firm pressure
  29. What can you hear in the Bell of you stethoscope
    Soft, low-pitched sounds: extra heart sounds, murmurs

    Use light pressure
  30. Problem- oriented medical records
    • SOAP
    • PIE
  31. What does SOAP stand for
    • Subjective
    • Objective
    • Assessment
    • Plan
Card Set
Assessment tools and tech