● Consider Maslow’s Hierarchy of Needs
● Assessment vs Intervention
Assessment-data that you re collection from the patient-vital signs, how much
they ate today
Interventions- Nursing interventions are informed by th
...
● Consider Maslow’s Hierarchy of Needs
● Assessment vs Intervention
Assessment-data that you re collection from the patient-vital signs, how much
they ate today
Interventions- Nursing interventions are informed by the results of nursing assessments.
While the ultimate goal of an assessment is to decide on a course of treatment, an
intervention in many cases is the treatment. Nursing interventions also go beyond simply
“fixing” a patient medically
Module 1- General Survey
● First impressions of patient
● Includes vital signs, weight, height
What are you looking for?
● Hygiene
● Posture
● Who is with the patient?
● Speech problems (education level,
ethnicity)
● Posture, gait, coordination
● Signs of distress
● Non-verbal cues
Module 1- Physical Exam
Inspection, palpation, percussion, auscultation○ Note: for abdominal exams, auscultation and palpation switch places
Know what each of these entails
○ Inspection
● Systematic
● using eyes, ears, smell
● focuses the rest of the nursing process
o Palpation
● light → deep
● touch painful area LAST
Rash-focus interventions on the rash
Palpations- touch most painful area last
○ Percussion
■ determines density
■ Tympany (gastric bubble), Hyper-resonance (emphysema), resonance
(normal lungs), dullness (organ, “short”), flat (muscle, “dead”)
○ Auscultation
■ Need your stethoscope: diaphragm (high pitched) vs bell (low
pitched)
■ Listening for quality (intensity, pitch, duration, “quiet”)
Percussion- tap
Flat sound-where would you hear… or
Auscultation- stethascope-diaogram high pitches sound-bell- low pitch sound – listen to
quality of sound, pitch, is it loud or soft.
Module 1- Pain
● SUBJECTIVE!!!
● Goals
● reduce and managing pain
● creating a plan with your patient
● Assess for congruency
● Does pain rating match their expression?
● Especially important in older adults
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