Putting It All Together

1
Putting It All Together

• Requires least up down movement on clients
  part least jumping around by assessor
• Should be well choreographed, organized, flexible
  smooth procedure should flow naturally
• Takes repeated practice rehearsal
• Cover all areas in an orderly sequence.

2
Preparation Opening

• Equipment needed
• Preparation of the setting
• Clients emotional state
• Your demeanor
• Introductions
• Preparation of client considering age
  developmental level.

3
Order

• Health History
• Physical Exam
• General appearance
• Measurement
• Skin
• Vital signs
• Head face
• Eyes, ears, nose throat
• Neck
• Chest posterior lateral
• Chest, Anterior

• Heart for murmers
• Upper Extremities  
• Breasts 
• Neck Vessels
•  Heart complete exam
• Abdomen
• Inguinal Area 
• Lower Extremities
• Neurologic
• Lower Extremities
• Musculoskeletal
•  Genitalia Rectum

4
Recording

• ASAP
• Data important for diagnosis treatment of
  client
• How do we then put all the data together?
• Collect subjective data during health history,
  objective data during physical exam together
  with clients medical record lab work provides
  the data base
• From data base you make a clinical judgement or
  diagnosis about individuals health state or
  response to actual or high risk health problems
  life processes
• Difficult for beginning to make leap from data
  base to diagnosis takes practice.

5
Four Components of Diagnostic Reasoning

• Attending to initially available cues (pieces of
  info, sign/symptom or piece of lab data)
• Formulating diagnostic hypothesis (tentative
  explanation for cue/set of cues)
• Gathering data relative to the tentative
  hypotheses supports/rejects hypothesis
• Evaluating each hypotheses with new data
  collected rule out some dx ? reach final list.

6
Diagnostic Hypothesis

• Develop preliminary list of significant
  signs/symptoms all client health needs
• Group together assessment data that appear to be
  associated or causal
• Organize data into meaningful clusters
• Validate any data you are unsure of
• Formulate diagnosis
• Order diagnosis by priority.

7
Diagnostic Priority

• First-level priority problems are emergent,
  life threatening immediate
• Second-level priority problems next in urgency,
  those requiring prompt intervention to forestall
  further deterioration
• Third-level priority problems those that are
  important to the clients health but can be
  addressed in a more deliberate manner more
  long-term.

8
Focused Multi-system Assessment

• Listen carefully to client concern what is
  complaint?
• What body systems are potentially involved?
• Think about the body what systems are closely
  inter-related?
• What do you need to rule out?
• Most health complaints lend themselves to a
  multi-system assessment, rare to assess just one
  system
• Take a complete health history pertaining to each
  of the systems you have identified always
  explore thoroughly any symptom PQRSTU.

9
Group Work

• Guess the systems to assess thoroughly then list
  health history assessment questions and physical
  assessment steps
• I have a cough
• I have a headache
• I passed out
• I have a sore stomach
• I feel breathless
• I have a sore calf
• I have a sore on my foot .