A stethoscope is a medical device for listening to sounds inside the body. The initial stethoscope was invented in the early 19th century by French physician Ren� Laennec, but was actually trying to achieve a rather different end: doctor-patient distance....
Nursing diagnosis for decreased cardiac output may be related to altered myocardial contractility, inotropic changes; alterations in rate, rhythm, electrical conduction; or structural changes, such as valvular defects and ventricular aneurysm. ...
The electrocardiogram (ECG) is a graphic recording ofelectric potentials generated by the heart.The signals are detected by means of metal electrodes attached to the extremities and chest wall and are then amplified and recorded by the electrocardiograph. ECG leads actually display the instantaneous differences in potential between these electrodes. ...
Assessment requires the use of the skills needed for interviewing, conducting a physical examination, and observing patients. As with the nursing process itself, these skills are not used one at a time. While you are interviewing the patient, you are also observing and determining physical areas that require a detailed physical assessment. While completing a physical assessment, you are asking questions (interviewing) and observing the patient’s physical appearance as well as the patient’s response to the physical examination.
Interviewing generally starts with gathering data for the nursing history. In this interview, you ask for general demographic information such as name, address, date of last hospitalization, age, allergies, current medications, and the reason the patient was admitted. Depending on the agency’s admission form, you may then progress to other specific questions or a physical assessment.
The physical assessment calls for four skills: inspection, palpation, percussion, and auscultation. Inspection means careful and systematic observation throughout the physical examination, such as observation for and recording of any skin lesions. Palpation is assessment by feeling and touching the patient. Assessing the differences in temperature between a patient’s upper and lower arm would be an example of palpation. Another common example of palpation is breast self-examination. Percussion involves touching, tapping, and listening. Percussion allows determination of the size, density, locations, and boundaries of the organs. Percussion is usually performed by placing the index or middle finger of one hand firmly on the skin and striking with the middle finger of the other hand. The resultant sound is dull if the body is solid under the fingers (such as at the location of the liver) and hollow if there is a body cavity under the finger (such as at the location of the abdominal cavity). Auscultation involves listening with a stethoscope and is used to help assess respiratory, circulatory, and gastrointestinal status.
The physical assessment may be performed using a head-to-toe approach, a body system approach, or a functional health pattern approach. In the head-to-toe approach, you begin with the patient’s general appearance and vital signs. You then progress, as the name indicates, from the head to the extremities.
The body system approach to physical assessment focuses on the major body systems. As the nurse is conducting the nursing history interview, she or he will get a firm idea of which body systems need detailed examination. An example is a cardiovascular examination, where the apical and radial pulses, blood pressure (BP), point of maximum intensity (PMI), heart sounds, and peripheral pulses are examined.
The functional health pattern approach is based on Gordon’s Functional Health Patterns typology and allows the collection of all types of data according to each pattern. This is the approach used by this book and leads to three levels of assessment. First is the overall admission assessment, where each pattern is assessed through the collection of objective and subjective data. This assessment indicates patterns that need further attention, which requires implementation of the second level of pattern assessment. The second level of pattern assessment indicates which nursing diagnoses within the pattern might be pertinent to this patient, which leads to the third level of assessment, the defining characteristics for each individual nursing diagnosis. Having a three-tiered assessment might seem complicated, but each assessment is so closely related that completion of the assessment is easy. A primary advantage in using this type of assessment is the validation it gives to the nurse that the resulting nursing diagnosis is the most correct diagnosis. Another benefit to using this type of assessment is that grouping of data is already accomplished and does not have to be a separate step.
Revisions of nursing standards created questions regarding the necessity of nursing care plans. Some have predicted the rapid demise of the care plan, according to Brider, but review of the revised nursing standards shows that the standards require not less but more detailed care planning documentation in the patient’s medical record.
Review of the new criteria indicates that the standards require documentation related to the nursing process. For example, the plan of care statement reads:
A plan, based on data gathering during patient assessment, that identifies the patient’s care needs, tests the strategy for providing services to meet those needs, documents treatment goals or objectives, outlines the criteria for terminating specified interventions, and documents the individual’s progress in meeting specified goals and objectives. The format of the “plan” in some organizations may be guided by patient-specific policies and procedures, protocols, practice guidelines, clinical paths, care maps, or a combination of these. The plan of care may include care, treatment, habilitation and rehabilitation.
Rather than eliminating care plans, the requirements call for a more specific as well as a more permanent documentation of the plan of care. This documentation must be in the medical record. The standard indicates that a separate care plan form is no longer necessary; however, the standard also still allows a separate care plan form. Various institutions are now testing flexible ways of documenting care planning. The care plan is not dead; rather, it is revised to more clearly reflect the important role of nursing in the patient’s care. No longer a separate, often discarded, and irrelevant page, the plan of care must be part of the permanent record. The flow sheets developed for this book offer guidelines for computerizing information regarding nursing care.
Faculty can use the revised standards to assist students in developing expertise beyond writing extensive nursing care plans. This additional expertise requires the new graduate to integrate all phases of the nursing process into the permanent record. Rather than eliminating the need for care planning and nursing diagnosis, the standards have reinforced the importance of nursing care and nursing diagnosis.
