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collaborate strategies and solutions. As you and the patient develop rapport with each other, the patient feels respected and understood.” (Jensen, 2015, p. 20).You should always utilize the nurse-patient relationship which focuses on verbal and nonverbal communication. It is our duty to maintain this professional relationship to ensure our patients get the proper care. Proper communication is the most crucial components of an assessment. (Jensen, 2015, p. 20).Through our interview, we collect subjective data which we will use to collect our objective data. The nurse should use open ended questions as much as possible to allow the patient to do most of the talking. We want to evoke more than a yes or no question. For example,
PATIENT ANALYSIS AND TEACHING TOOL4asking, “What brought you in today?” or “Tell me more about how you manage your diabetes.” allows the patient to be the focus of the interview. The nurse should always utilize therapeutic communication and empathy when dealing with patients. (Jensen, 2015, p. 20). When moving onto the physical aspect of the assessment, it’s crucial to know your audience. Some patients have not had much experience with healthcare, so they might not know what to expect. Always explain what and why you are doing. In addition, certain religions might not favor physical contact as much – therefore always ask before you touch.Data Collection & Appropriateness of Data Collection TechniquesEvery single body system starts off with inspection. You can collect a lot of data just by looking at the individual i.e. psoriasis, scoliosis, hirsutism and overall well-being. By looking at Ms. Jones, I was able to identify that she has acanthosis nigricans, acne, protuberant abdomen, striae and moles. Following inspection comes palpation (except with the abdomen). With palpation, you can assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus, tenderness, pain and edema. (Jensen, 2015, p. 49). As stated above, always ask if you can touch them prior to doing so. Light palpation can allow the patient to get used to your touch. (Jensen, 2015, p. 49). You should start off light to identify any areas of pain; the patient may not be able to initially handle the deep palpation. Afterwards, tell the patient “I am going to press harder now, tell me if you feel pain or want me to stop”. Deep palpation allows you to assess the size, shape and consistency of abdominal organs. However, you should not palpate after inspection with the abdomen. With the abdominal system, palpation is the third step (auscultation is second). “Auscultation is performed following inspection; the abdomen should be auscultated
PATIENT ANALYSIS AND TEACHING TOOL5before percussion or palpation to prevent production of false bowel sounds.” (AMN Healthcare, 2014).Next, you percuss. Percussion produces sound or elicits tenderness. You will percuss the lungs, abdomen, flank and sinuses. I used this technique to identify if Ms. Jones has healthy lungs (resonance), measuring the dullness and size of her liver and kidney problems (CVA tenderness).