Nursing Process: Assessment

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Nursing Process - allows nurses to have some type of plan before meeting a patient

Nursing Care -

no longer provide the same care to patients because they are all DIFFERENT (abilities, cultural backgrounds, etc.)

Holistic View (Body, Mind and Spirit - Look at everything)

Assessment

Systemic gathering of information related to physical, mental, spiritual, socioeconomic and cultural status of an individual, group or community

Includes:

Collecting Data

Using a systemic and ongoing process

Categorizing data

Recording data

Relation to Other Steps

Diagnosis

Data used to identify health problems and strengths to establish a diagnosis

Planning Outcomes

Data about motivation, family and resources to help formulate realistic goals and choose interventions

Implementation

Gather data by observing responses which can help identify a new diagnosis

Evaluation

You assess client responses to interventions for data

Provides the basis for changes in the care plan

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How are Data used?

Used for collaboration

The process that allows a nurse to make referrals to other professionals with expertise in a particular area of healthcare

To plan for nursing care

Ensure clients receive: proper care by qualified individuals at the time it is needed

What is the Difference?

Medical Assessments = focus on the disease and pathology

Nursing Assessments = focus on the client's response to an illness

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Can I Delegate Assessments?

Nurse aides or other nursing assistive personnel (NAP) may collect information such as temperature, height, and weight.

Nurse assigns tasks, validates data gathered, conducts interviews and completes the physical assessment

YOU are responsible for whoever you delegate

Can delegate very basic things such as bed baths and vital signs

You must always check up on your patients regardless of who you delegate

ALWAYS want to look over

Both need to provide optimal patient care

Resources for Delegating

State Nurse Practice Acts

Specifies which portions of assessment can legally be completed by individuals with different credentials

Agency policies/ procedures

Provide guidance about which caregivers can collect and document specified data

Accrediting Agencies

Also provide guidelines on who can perform and document assessments

ANA

Guide decisions on who is ultimately responsible and qualified to collect data assessment

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Types of Assessment

Initial

The assessment that occurs when you first meet this patient

Provides baseline data

Holistic approach

Get patient's entire history

First obtain data related to the patient's reason for seeking assistance

Determines the need for further assessmnt

Provides guidance for care

Ongoing

Used to identify new problems

Follow up on previously identified problems

Comprehensive

Head to toe assessment

Holistic assessment of body, mind and spirit

Ask about everything: family, community, culture and etc.

Complete nursing history and physical examination

Focused

Focused on the problem at hand

Special Needs

Type of focused assessment

Performed anytime assessment cues suggest risk factors or problems in an area of client functioning

Ex. Help patients with decreased functional abilities

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Special Needs Assessments

Nutritional

Check for imbalanced nutrition or if nutritional therapy is required

Take information about food intake and any factors affecting nutrition

Pain

Required to perform a thorough pain assessment on all patients during the initial assessment and in ongoing assessments

Functional Abilitiy

Important esp. with discharge planning and home care

Tools for assessment:

Katz index of ADL scale

Assigns points for bathing, dressing, toileting, transfer, continence and feeding

Lawton Instrumental Activities of Daily Living (IADL)

Assesses a person's ability to independently perform the more sophisticated tasks of everyday life (ex. shopping)

Helps identify an functional decline

The Karnofsky Performance Scale

Used palliative care settings to assess functional abilities at the end of life

Cultural

Cultural influences should guide assessment and nursing care

Do not stereotype clients based on culture

Competent = assess and honor the diversity among all clients

Spiritual Health

Can be a problem or source of support

Provides insight into how a client interprets life events and health

Psychosocial

Data about lifestyle, usual coping patterns, current illness, personality, previous psychiatric disorders, recent stressors, major issues related to illness and mental status

Done if initial assessment identifies social and emotional needs are not being met

OR if sociocultural factors present a risk at health

Wellness

Well people = can identify their own health needs

Assesses spiritual health, social support, nutrition, physical fitness, health beliefs, lifestyle and stress.

Health promotion focuses on achieving a higher level of health

Family

Behaviors and beliefs usually begin with family interactions

Provides better understanding of a client's values, beliefs and behaviors

Community

Provides information about demographics, resources, health concerns, points of referral, environmental risks, norms and values

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Basic Physical Assessment Techniques

Inspection

Observation and visual examination of the client

Use of equipment such as an otoscope or opthalmoscope

Palpation

Light touch to deep touch

Using pads of the fingers

Percussion

Striking a body surface with the tip of a finger

Produces different vibrations

Sounds depend under that area that is tapped (air, fluid or solid)

Auscultation

Direct - listening with unaided ear for sounds made by the client

Indirect - listening with the use of a stethoscope for normal and abnormal sounds within the body

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The Nursing Interview

Purposeful + Structured Communication

Involves questioning the client

Purpose: Gather subjective data for the nursing database

Directive Interview

Control the topics

Close ended questions to obtain specific information

Obtain factual and easily categorized information

Nondirective Interview

Used to promote communication, build rapport or help patient express feelings

Allows the patient to control the subject matter

Nurse's Role = Clarify, summarize and ask open-ended questions

Preparing for the Interview

Know the purpose of the interview and the data

Read the client's chart

Form some goals and opening questions

Schedule uninterrupted time

Have forms and equipment ready

Compose yourself

Good Interview Space

Privacy

Comfort

Lighting

Make sure you have enough time

Preparing the Client

Introduce yourself

Call the client

Tell the client what you will be doing and why

Assess readiness

Provide comfort

Assess for anxiety

Be focused on the patient

Be mindful that you want to help them

Be respectful

Remember that it is a professional relationship

Conducting the Interview

Individualize your approach

Use active listening

Pay attention to nonverbal communication

Use open-ended questions

Avoid medial jargon

Curb curiosity

Do not advise or voice opinions

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Collecting data:

In the patient’s medical record - from interviewing the patient and/or his or her family

Physical assessment

From other interdisciplinary team members such as clergy or social workers

Systematic and ongoing process:

Working in a systematic fashion allows you to stay organized and not miss important data; ongoing refers to process being constantly changing as new information is revealed.

Categorizing data:

This could include putting data into main categories such as physical, mental, spiritual, socioeconomic, and cultural.

Recording data:

You will record the data in order to have a patient database from which you can develop a plan of care.

Validating Data:

When

Subjective/Objective data do not agree or make sense

Client's statements are inconcsistent

Data are far outside normal range

Factors present that interfere with accurate measurement

Documenting Data

Document as soon as possible

Write legibly

Avoid using inferences

use client's words

Record only pertinent, important and relevant data

Reflecting on the Assessment

Are my data complete, accurate and validated?

Record data not conclusions

Follow up special needs

Think about the client interview

Review assessment, observation and examination