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Physical Assessment for Nurses and Healthcare Professionals

  • Erscheinungsdatum: 19.02.2019
  • Verlag: Wiley-Blackwell
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Physical Assessment for Nurses and Healthcare Professionals

Physical Assessment for Health Care Professionals offers a practical and comprehensive guide to best clinical practice when taking patient history and physical examination. This accessible text is structured in accordance with the competencies for advanced practice in assessment, diagnosis and treatment as published by the RCN. Following a systematic, systems-based approach to patient assessment, it includes a summary of the key clinical skills needed to develop and improve clinical examination in order to confidently assess, diagnose, plan and provide outstanding care. In this revised edition, colour photographs and case studies have been included to assist health care practitioners in their assessment of the patient. This important guide: Includes a highly visual colour presentation with photographs and illustrations. Features a wide range of key learning points to help guide practice. Offers illustrative examples, applications to practice and case studies. Is available in a range of digital formats - perfect for 'on the go' study and reference.
Written for health care students, newly qualified and advanced nurse practitioners, and those in the allied health professions, Physical Assessment for Health Care Professionals is the essential guide for developing the skills needed to accurately access patient history and physical examination. Carol Lynn Cox is Professor Emeritus, School of Health Sciences, City, University of London, UK, and Clinic Manager and Director of Nursing, Health and Hope Clinics, Pensacola, Florida, USA.


    Format: ePUB
    Kopierschutz: AdobeDRM
    Seitenzahl: 480
    Erscheinungsdatum: 19.02.2019
    Sprache: Englisch
    ISBN: 9781119108993
    Verlag: Wiley-Blackwell
    Größe: 32546 kBytes
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Physical Assessment for Nurses and Healthcare Professionals

Introduction: The First Approach

Carol Lynn Cox
General Principles

It is important to understand that for the purposes of examination, assessment, and diagnosis, doctors are framing their approach to the patient from the perspective of the medical model. However, you must recognise that as an allied healthcare practitioner, you are employing the medical model within your frame of practice. Therefore, to be wholistic, the approach incorporates all aspects of your particular discipline (e.g. audiology, nursing, midwifery, physiotherapy, occupational therapy, radiography, respiratory therapy, speech therapy).
General Objectives

When you approach a patient there are four initial objectives you should consider:

Obtain a professional rapport with the patient and gain their confidence.
Obtain all relevant information that allows assessment of the illness and provisional diagnoses.
Obtain general information regarding the patient and their background, social situation, and problems. In particular, it is necessary to find out how the illness has affected the patient, their family, friends, colleagues, and life.

A wholistic assessment of the patient is of utmost importance.
Understand the patient's own ideas about their problems, major concerns, and expectations of the hospital admission, outpatient, or general practice consultation.
Remember medicine is just as much about worry as disease. Whatever the illness, whether chest infection or cancer, anxiety about what may happen is often uppermost in the patient's mind (Clark 1999 ; Japp and Robertson 2013 ; NHS Wales 2010 ).
Listen Attentively (Engage in Active Listening.)

Engage in active listening

The following notes provide a guide as to how the healthcare practitioner obtains the necessary information.
Specific Objectives

In taking a history or conducting a physical examination there are several complementary aims:

Obtain all possible information about a patient and the illness (a database) from both a subjective and objective perspective.
Consider all possible differential diagnoses related to the patient and the illness.
Formulate the diagnoses from the patient's subjective, objective physical examination and investigative tests (e.g. laboratory, radiologic, and other).
Solve the problem as to the diagnoses (Bickley and Szilagyi 2013 ; Japp and Robertson 2013 ; Jarvis 2015 ). Analytical Approach

For each symptom or sign you need to think of a differential diagnosis and of other relevant information (from the history, physical examination, and/or investigative tests) that will be needed to support or refute possible diagnoses. A good history, physical examination, and investigation include these two facets and can be viewed as either positive (support) or negative (refute) findings. To achieve a formal diagnosis, following differential diagnosis, critical thinking/clinical decision making is used to examine positive and negative findings. Healthcare practitioners frequently find that using the first two components of the Subjective, Objective, Assessment, and Plan (SOAP) (Clark 1999 ) format can help them formulate their diagnosis. You should never approach the patient with just a set series of rote questions. Frequently in preassessment clinics, ambulatory services (outpatient) clinics, or general practice settings, standard assessment forms within an electronic patient record (EPR) are used as a guide to history taking. However, there are some instances in which paper records are employed. These tools provide the necessary basis for a later, more inquisitive approach that should develop as knowledge about

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