Research for the establishment of physical assessment practices at internal medicine wards and outpatient clinics

点击翻译按钮获取中文摘要

Purport : Identifying the usage status of physical assessment items among nurses at internal medicine wardsMethod : In the fiscal year 2005, the study used the participant observation approach to examine anamnesis and thermometry at hospitalization to identify what physical assessment items were actually used, covering 11 nurses working at the internal medicine wards (37 beds) of a regional hub hospital (395 beds) and medical records of 22 cases handled at the same wards. In the fiscal 2006, questionnaires were distributed to the same facility's 22 nurses who had taken part in the Physical Assessment Training (held in 2004), and five of them who consented were subsequently interviewed.Findings : The participant observation approach was used on 13 occasions (8 anamnesis occasions and 5 thermometry occasion). The observation covered 2 cases of cerebral infarction, 3 cases of dialysis initiation, and one case each of hyperglycemia / acidosis, renal biopsy and fever of unknown origin. At t … More he time of anamnesis, all study subjects used the facility's basic information sheet to interview patients, measuring vital signs and oxygen saturation, as well as conducting palpation for edema. Medical records of 22 cases covered 10 cases of pneumonia, 4 cases of diabetes, 2 cases of nephritis, and one case each of SLE, cerebral infarction, muscular dystrophy, fever of unknown origin, nephritic syndrome and disseminated necrotizing periarteritis. Description in the records mainly consisted of responses to questions in the basic information sheet, results of vital sign measurements and the extent of independence in daily life activities. After the Physical Assessment Training, surveyed nurses (with the average age of 41.5) cited items on the "respiratory" and "circulatory" systems as useful, while branding items on the "musculo-skeletal", "nervous" and "receptive" systems as not useful. They also commented that the Training "increased their knowledge", "broadened the range of skills" and "enhanced the observation skill to see patients in a more comprehensive approach", while also expressing that they should further develop the ability to accurately grasp patients' physical conditions. Less