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How to Perform a Basic Head to Toe Nursing Assessment
The assessment process involves four closely related activities: Goals may be short-term or long-term, should be singular in nature and must focus on the individual outcome. By performing regular evaluations medical professionals can determine the appropriate course of action, identify potential errors and ensure that the process is working as smoothly as possible. It is an excellent time to gain further information about the patient. It may also include coaching, counseling and providing feedback to the individual. This will be discussed in Chapter 8. Most people feel comfortable maintaining a distance of 3 to 4 feet during an interview. Nursing assessments do not focus upon disease, as do medical assessments. They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination. Plan for the next meeting, if there is to be one. Chapter 4 The Nursing Process The problem solving model for nursing is called the nursing process.
The implementation phase may be performed using a combination of direct care and indirect care. In contrast, a seating arrangement in which the parties sit on two chairs placed at right angles to a desk or table or a few feet apart, with no table between, creates a less formal atmosphere. Observation occurs whenever the nurse is in contact with the client or support persons. After the problems have been identified and prioritized the phase of the process is planning. There are four kinds of interview questions, namely, closed or open-ended questions, and neutral or leading. You may extend your knowledge of existing problems or gain insight that will lead you to identify new ones Ellis, Nowlis, Bentz, By performing regular evaluations medical professionals can determine the appropriate course of action, identify potential errors and ensure that the process is working as smoothly as possible. Family members or other support persons, other health professionals, records and reports, laboratory and diagnostic analyses, and relevant literature are called secondary sources. Data Collection Methods The primary methods used to collect data are observing, interviewing, and examining. The assessment process involves four closely related activities: By implementing the process medical professionals are able to assess the patients condition through the collection of subjective and objective data, develop a diagnosis based on the information that has been collected, create a plan with interventions and SMART goals for the patient to follow, implement the process to achieve the plans goals and evaluate the individuals performance and ability to achieve their goals through the implementation of a care plan. Evaluations should be performed throughout the ADPIE process on a regular basis in order to assess the plan and make adjustments when they need to be made. The opening can be the most important part of the interview because what is said and done at that time sets the tone for the remainder of the interview. Objective Part of Data Collection The physical examination or physical assessment is a systematic data-collection method that uses observational skills, such as the senses of sight, hearing, smell, and touch, to detect health problems. Upon developing smart goals the medical professional should determine whether or not the goals are a good fit for the individual and able to be easily attained. Planning Planning is the process of developing a plan and establishing SMART goals in order to achieve a desired outcome such as reducing pain or improving cardiovascular function. Finally, provide summary to verify accuracy and agreement. They also provide medical professionals with a plan in which they can measure and evaluate the individuals improvements. Then, you plan on the things you should do to resolve the nursing diagnosis. The distance between the interviewer and interviewee should be neither too small nor too great, because people feel uncomfortable when talking to someone who is too close or too far away. A seating arrangement with the nurse behind a desk and the client seated across creates a formal setting. The closing is important in maintaining the rapport and trust and in facilitating future interactions. Afterwards, you implement the interventions to the patient. Stages of Interview An interview has three major stages, the opening or introduction, the body or development, and the closing. The client is the primary source of data.
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