Physical

An Overview
Assessment

J. Carley RN, MSN, MA, CNE

Fall, 2009

Youre
Late !
Lets Start

Rm. 3A:

Rm. 4A:

Rm. 5A:

Rm. 6A:

Rm. 7A:

Velma Aguon
76 y.o. P.I.-Am. Female
DX: Hypertensive
Crisis

Mike Smithe
32 y.o. Afr-Am Male

Julian Reilly 44 y.o.

Cauc.
Male
DX: Pericarditis

Ashley Wilkes
26 y.o. Cauc.
Female
DX: Mitral Stenosis

Emsley Owens
72 y.o. Afr-Am
Male
DX: CHF

DX:

R/O M.I., HTN

RNs Comment: Oh, *&%

$#!!!

New
Admission

Rm. 8A:

Rm. 9A:

Rm. 10A:

Rm. 11A:

Rm. 12A:

Redd Butler
56 y.o Cauc.
DX: Cardiomyopathy,
CHF

Faith Hopee
78 y.o. N.A.
Female
DX: A- Fib

Frank Arbugast
18 y.o. Afr-Am
Male

Aubrey Embry
38 y.o. J.A.
Female
DX: Endocarditis

Yolanda Zahara
55 y.o. M.E. A.
Female

DX: Sickle-Cell Cr.

DX: Buergers Disease

mnemonic

Nursing
Process

A-D-O-P-IE

Assessme
nt
Diagnosis
Outcome
Identificati
on

Planning
Intervent
ion
Evaluatio
n
List of NANDA Nursing Diagnoses

Content and Process

of This Course !

The
Nursing
Process

A Closer Look

Assessment
Collect Data:
Review the Clinical Record

Interview
Health History
Physical Examination
Functional Assessment
Consultation
* Review of the Literature
(--Evidence Based Practice)

Diagnosis
*Interpret Data:
Identify clusters / cues
Make Inferences
* Validate Inferences
* Compare clusters of cues w/ definition,
defining characteristics
* Identify Related Factors
* Document the nursing diagnosis

Outcome
Identification
--Identify expected outcomes
--INDIVIDUALIZE to the person
--Realistic and MEASURABLE
--Include a TIME FRAME

Planning
--Establish priorities
--Develop Outcomes
--Set time frames for outcomes
--Identify Interventions
--Document Plan of Care
The Nursing Care Plan

Implementation
--Review planned interventions
--Schedule & coordinate patients care
--Collaborate w/ other team members
--Supervise implementation by
delegation
--Counsel patient & family
--Involve the patient in their care
--Referrals as need for continuity of care
--Document care provided

Evaluation
--Refer to the outcomes you established
--Evaluate individuals condition: compare
actual outcomes to expected outcomes
--Summarize results of the evaluation
--If expected outcomes not met, identify
reasons
--Modify Plan of Care as necessary
--Document Evaluation of Outcomes, and
changes (if any) in Plan of Care

Nursing
Process
Assessme
nt
Diagnosis
Outcome
Identificati
on

Planning
Intervent
ion
Evaluatio
n

mnemonic

A-D-O-P-I-E

Subjective Data
Objective Data

Objective
Data:

Blood Pressure = 142 / 98 mm

Hg
Weight = 158 lbs (= 71.8 kg)
Oral Intake = 2400 mL / 24
hours
Urinary Output = 250 mL / 24
hours
Imbalance Between Oral Intake &
Urinary Output (above)

The Interview

Yes.

Uh Huh.

I see

The
Intervie
w

During the interview, it is a chance for the patient to tell you how he or she
PERCEIVES what is going onwhat they THINK (or want you to think) their
health state is

U2: Your Blue Room

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Learning Games

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Part 2:
Interviewing &
The Nursing
Documentatio
Interview
n

The Nursing
Process
Mnemonic: ADOPIE = The Nursing Process
Assessment

Evaluation

Diagnosis

Outcome
Identification
Implementation

Planning

Establish Rapport

Get organized
Do not rely on memory
Plan enough time
Ensure privacy
Get focused
Be calm, confident, warm, and
helpful

Begin the Interview

Give your name

and position
Verify the clients
name
Briefly explain your
purpose

How to listen

Be an empathetic listener
Use short supplementary phrases
Listen for feelings as well as words
Let the person know when you see body
language that conflicts with what they say
Be patient if the patient has a memory
block
Avoid the impulse to interrupt
Allow for pauses

How to ask Questions

Ask about the main problem first = chief
complaint
Focus your questions to gain specific
information about the signs and symptoms
Dont lead the witness
Restate the other persons words to clarify
Use open-ended questions
Avoid closed ended, yes or no questions

How to terminate the

interview
If the session has been long, give
a warning
As the person to summarize their
primary concerns
Ask if there are other areas to be
discussed
Offer yourself as a resource
Explain routines and provide
information about who does what
End on a positive note

Charting &
Documentation
If it isnt written, then it wasnt
done
Chart at the time it occurs if
possible
Follow facility guidelines
Is the information clear and
logical?
Is it true?
Is it non - judgmental?
Record all abnormals and normals

Charting guidelines

Be precise
Stick to the facts
Sign your name after each entry
SOAP format focuses on specific
problems
AIR, DAR, PIE, DIE formats focus
on nursing interventions and
client response
Prioritize the client problems

Part Two:
Complete Health
History

Biographical Data
Reasons for Seeking Health Care
History of Present Health Concern
Past Health History
Family Health History

Lifestyle and Health

Practices Profile

Description of Typical Day

Nutrition and Weight Management
Activity Level and Exercise
Sleep and Rest
Medication and Substance Use
Self-Concept
Self-Care Responsibilities

NANDA Nursing Diagnosis List

Activity Intolerance
Activity Intolerance, Risk for
Airway Clearance, Ineffective
Anxiety
Anxiety, Death
Aspiration, Risk for
Attachment, Parent/Infant/Child, Risk for Impaired
Autonomic Dysreflexia
Autonomic Dysreflexia, Risk for
Blood Glucose, Risk for Unstable
Body Image, Disturbed
Body Temperature: Imbalanced,
Risk for
Bowel Incontinence
Breastfeeding, Effective
Breastfeeding, Ineffective
Breastfeeding, Interrupted
Breathing Pattern, Ineffective

Cardiac Output, Decreased

Caregiver Role Strain
Caregiver Role Strain, Risk for
Comfort, Readiness for Enhanced
Communication: Impaired, Verbal
Communication, Readiness for Enhanced
Confusion, Acute
Confusion, Acute, Risk for
Confusion, Chronic
Constipation
Constipation, Perceived
Constipation, Risk for
Contamination
Contamination, Risk for
Coping: Community, Ineffective
Coping: Community, Readiness for Enhanced
Coping, DefensiveCoping: Family, Compromised
Coping: Family, Disabled
Coping: Family, Readiness for Enhanced
Coping (Individual), Readiness for Enhanced
Coping, IneffectiveDecisional Conflict

Decision Making, Readiness for

Enhanced
Denial, Ineffective
Dentition, Impaired
Development: Delayed, Risk
forDiarrhea
Disuse Syndrome, Risk for
Diversional Activity, Deficient
Energy Field, Disturbed
Environmental Interpretation Syndrome, Impaired
Failure to Thrive, Adult
Falls, Risk for
Family Processes, Dysfunctional: Alcoholism
Family Processes, Interrupted
Family Processes, Readiness for Enhanced
FatigueFearFluid Balance, Readiness for Enhanced
Fluid Volume, Deficient
Fluid Volume, Deficient, Risk for
Fluid Volume, Excess
Fluid Volume, Imbalanced, Risk for

Gas Exchange, Impaired

Grieving
Grieving, Complicated
Grieving, Risk for Complicated
Growth, Disproportionate, Risk for
Growth and Development, Delayed
Health Behavior, Risk-Prone
Health Maintenance, Ineffective
Health-Seeking Behaviors (Specify)
Home Maintenance, Impaired
Hope, Readiness for Enhanced
Hopelessness
Human Dignity, Risk for Compromised
Hyperthermia
Hypothermia
Immunization Status, Readiness for Enhanced

Infant Behavior, Disorganized

nfant Behavior: Disorganized, Risk for
Infant Behavior: Organized, Readiness for Enhanced
Infant Feeding Pattern, Ineffective
Infection, Risk for
Injury, Risk for
Insomnia
Intracranial Adaptive Capacity, Decreased
Knowledge, Deficient (Specify)
Knowledge (Specify), Readiness for Enhanced
Latex Allergy Response
Latex Allergy Response, Risk for
Liver Function, Impaired, Risk for
Loneliness, Risk for

Memory, Impaired
Mobility: Bed, Impaired
Mobility: Physical, Impaired
Mobility: Wheelchair, Impaired Moral Distress
Nausea
Neurovascular Dysfunction: Peripheral, Risk for
Noncompliance (Specify)
Nutrition, Imbalanced: Less than Body
Requirements
Nutrition, Imbalanced: More than Body
Requirements
Nutrition, Imbalanced: More than Body
Requirements, Risk for
Nutrition, Readiness for Enhanced
Oral Mucous Membrane, Impaired

Pain, Acute
Pain, Chronic
Parenting, Impaired
Parenting, Readiness for Enhanced
Parenting, Risk for Impaired
Perioperative Positioning Injury, Risk for
Personal Identity, Disturbed
Poisoning, Risk for
Post-Trauma Syndrome
Post-Trauma Syndrome, Risk for
Power, Readiness for Enhanced
Powerlessness
Powerlessness, Risk for
Protection, Ineffective
Rape-Trauma Syndrome
Rape-Trauma Syndrome: Compound Reaction
Rape-Trauma Syndrome: Silent Reaction

Religiosity, Impaired
Religiosity, Readiness for Enhanced
Religiosity, Risk for Impaired
Relocation Stress Syndrome
Relocation Stress Syndrome, Risk for
Role Conflict, Parental
Role Performance, Ineffective
Sedentary Lifestyle
Self-Care, Readiness for Enhanced
Self-Care Deficit: Bathing/Hygiene
Self-Care Deficit: Dressing/Grooming
Self-Care Deficit: Feeding Self-Care Deficit: Toileting
Self-Concept, Readiness for Enhanced
Self-Esteem, Chronic Low
Self-Esteem, Situational Low
Self-Esteem, Risk for Situational Low
Self-Mutilation
Self-Mutilation, Risk for

Sensory Perception, Disturbed

(Specify: Auditory,Gustatory, Kinesthetic, Olfactory Tactile,Visual)
Sexual Dysfunction
Sexuality Pattern, Ineffective
Skin Integrity, Impaired
Skin Integrity, Risk for Impaired
Sleep Deprivation
Sleep, Readiness for Enhanced
Social Interaction, Impaired
Social Isolation
Sorrow, Chronic
Spiritual Distress
Spiritual Distress, Risk for
Spiritual Well-Being, Readiness for Enhanced
Spontaneous Ventilation, Impaired
Stress, Overload
Sudden Infant Death Syndrome, Risk for
Suffocation, Risk for

Suicide, Risk for

Surgical Recovery, Delayed
Swallowing, Impaired
Therapeutic Regimen Management: Community,Ineffective
Therapeutic Regimen Management, Effective
Therapeutic Regimen Management: Family,Ineffective
Therapeutic Regimen Management, Ineffective
Therapeutic Regimen Management, Readiness for Enhanced
Thermoregulation, Ineffective
Thought Processes, Disturbed
Tissue Integrity, Impaired
Tissue Perfusion, Ineffective (Specify:
Cerebral,Cardiopulmonary, Gastrointestinal, Renal)
Tissue Perfusion, Ineffective, Peripheral
Transfer Ability, Impaired
Trauma, Risk for

Unilateral Neglect
Urinary Elimination, Impaired
Urinary Elimination, Readiness for Enhanced
Urinary Incontinence, Functional
Urinary Incontinence, Overflow
Urinary Incontinence, Reflex
Urinary Incontinence, Stress
Urinary Incontinence, Total
Urinary Incontinence, Urge
Urinary Incontinence, Risk for Urge Urinary Retention
Ventilatory Weaning Response, Dysfunctional
Violence: Other-Directed, Risk for
Violence: Self-Directed, Risk for
Walking, Impaired
Wandering

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