Chapter 16: Nursing Assessment

Chapter 16: Nursing Assessment

1. The Nursing Process: A five step process; fundamental blueprint for how to care for patients

   • Five Steps of the Nursing Process
     • Assess- Gather information about the patients condition
       • Diagnose- Identify the patients problem
         • Plan- Set goals of care and identify what nursing actions need to take place
           • Implement- Perform the planned interventions
             • Evaluate- Determine whether or not the interventions were effective
       • Assessment must be complete and thorough in order to correctly diagnose and improve one's health.

2. The Critical Thinking Approach to Assessment

   • Critical Thinking is a VITAL part of the assessment.
     • Apply your knowledge
     • Recall previous experiences that are similar
   • Nursing Assessment includes two steps
     • 1. Collect information from a primary (patient) and secondary source(family, health record, health team)
       • ex: ask questions, make observations, record health history etc.
     • 2. Interpret and validate the data
       • ex: if an area looks tender or inflamed, validate the presence by asking the patient if the area is tender

3. Developing a Nurse Patient Relationship for Data Collection

   • Data comes from the patient, family or friends, the health care team, medical records, and scientific and medical literature.
   • Always start by taking time to be with a patient, even if it is a small amount of time.
   • Show interest in the patients problems as this will build trust
   • Rounding is an important opportunity to build trust.
   • Develop a Therapeutic Relationship

4. Types of Assessments

   • Think critically about to asses for that specific patient at that specific time.
   • Use cues to make inferences
     • A cue is information you gain through the senses. ex: a person crying is a cue something is wrong.
     • Inferences are your interpretations of the cues. ex: you heard a patient crying which could possibly imply they are hurt or scared.
   • REMEMBER: the more you conduct assessments the better your thinking process will be. Thinking is natural and mistakes will happen.
   • First approach to a comprehensive assessment: General to specific
     • Assess a patient according to health patterns (ex: Gordon's 11 functional health patterns) then ask more specific questions
   • Second approach to a comprehensive assessment
     • Begin with the problematic area
       • Then ask follow up questions to get the full story

5. Types of Data

   • Subjective: A patients verbal description which include feelings or self- report symptoms
   • Objective: Observations of the patient, often measured to a certain standard. Remember to apply critical thinking to objective data.

6. Sources of Data

   • The patient
     • Best source of info, however, keep in mind their literacy level when asking questions.
   • Family and Significant Others
     • Primary Sources when dealing with kids
     • Recognize change in patients patterns
     • Make important observation that can affect the way care is delivered
   • Health Care Team
     • Every member of the team is important and offers vital information about the patient.
   • Medical Records
     • Valuable tool in checking the consistency of your own work with the data provided
     • HIPPA
       • Protect a patients health information at all tiimes
   • Other records and Scientific Lit
     • Read up on the illness a patent has to complete an assessment
       • Familiarize yourself with their specific illness or condition
   • Your own experience
     • Practical experience and having the opportunity to make critical decisions strengthens your critical thinking skills!

7. Patient Centered Interview

   • What are the Patients concerns?
   • What are the patients expectations?
   • Show interest and care.
   • Basis for foreign trust with the patient
   • Begin with courtesy (May I call you Ms. Smith or your first name.), address others in the room, ask permission to conduct the interview.
     • Make the patient comfortable: adjust room temp., good lighting, maintain privacy, etc.
       • Make a connection by establishing eye contact, staying at eye level with the patient
         • Don't just stare at the computer!
         • Ask open ended questions and observe their behavior when asking.
         • Confirmation: end the interview with questions like "Is there anything else you would like to share?"
   • Ask open ended questions
   • Observe the patients body language, eye contact, tone, etc.
   • Let a patient know you are listening by answering with "uh-huh or go on" while recording
   • MAKE NO ASSUMPTIONS

8. Nursing Health History

   • Cultural Consideration
     • Avoid making stereotypes
     • Adapt each assessment to the unique patient and their background
     • Understand exactly what they are saying
     • Clarify to prevent any mistakes!
   • Components of Nursing Health History
     • Biographical info (usually collected by admitting office) such as age, address, occupation, work status, martial status
     • Family History: determine if patient is at risk of certain diseases.
       • Also reveals family structure which may be useful in planning
       • Can be a significant barrier if family relationship is stressed
     • Health History
       • Include complete medication history
       • Description of allergies
       • Patients habits or lifestyle
       • Assess patterns of sleep, exercise and nutrition
     • Reason for seeking care
       • Ask a patient why they are seeking care
     • Patients expectations
       • Continuously check to see if their expectations have been met
     • Present illness or Health concern
       • PQRST
         • P- Provokes: What causes symptom, what makes symptoms worse?
         • Q- Quality: What does the symptom feel like? ex: sharp or dull pain
         • R- Radiate: Where is the symptom located?
           • Be as precise as possible
         • S- Severity: 0-10 pain scale
         • T-Time: When did the pain start, Does it come and go, how often, how long, what time of day or week? etc.
       • Collect essentail data about the symptoms and the effect they have on the patient
   • Observation of Patient Behavior
     • Pay attention to verbal and non verbal cues
       • Objective data can be collected, ex: observe patients level of functioning
   • Diagnostic and Laboratory Data
     • Compare data with establish norms for a particular test, age group ect.
   • Interpreting and Validating Assessment Data
     • Interpretation: Determine presence of abnormal findings and recognize further observation need to be made.
       • Reveals clusters which are pattern of data
         • Clusters reveals signs or symptoms that are grouped together in a logical way
           • These clusters identify the patients health problems
     • Validation: compare data with another source to determine accuracy
       • Family and friends often validate info.
       • Clarifies any unclear or vague data.
   • Data Documentation
     • Be clear and concise
     • Accurate and reliable data collection is essential to in the role of a professional nurse
     • Be as descriptive as possible
     • Any subjective matter should be in quotes