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Define and describe the purpose of four type of nursing assessments
- 1. Inital Assessment: assessment done shortly after the pt was admitted, and purpose is for establishing a complete database and for problem identification and care planning.
- 2. Focus Assessment: nurse gathers data about a specific problem... may be done during inital assessment if pt. health problems surface, but is routinely done as part of ongoing data collection. The purpose is identify new or overlooked problems.
- 3. Time-Lapsed Assessment: Is scheduled to compare a pt.'s current status to baseline data obtained earlier. Most pts in residential settings and those receiving nursing care over longer periods of time are scheduled for this to reassess health status and make revisions in plan of care.
- 4. Emergency Assessment: When a physiological/psychological problem presents, it's to identify life-threatening problems.
Explain the relationship between nursing assessment and medical assessment
When nurses make nursing assessments, they do not duplicate medical assessments. Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient’s responses to health problems.For example, is there interference with the patient’s ability to meet basic human needs? Can the patient perform the activities of daily living? Although the findings from a nursing assessment may contribute to the identification of a medical diagnosis, the unique focus of nursing assessments is on the patient’s responses to actual or potential health problems.
What are the different types of data and their definitions? Differentiate between them.
Subjective and objective data. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous,nauseated, or chilly and experiencing pain. Subjective data also are called symptoms or covert data.Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same patient.Examples of objective data are an elevated temperature reading(e.g., 101F), skin that is moist, and refusal to look at or eat food. Objective data also are called signs or overt data.
Identify five sources of pt. data useful to the nurse
The primary source of patient information is the patient. Resources include the patient’s support people, the patient record, information from other healthcare professionals,and information from nursing and healthcare literature.
Describe the purpose of nursing observation, interview, and physical assessment.
Observation is a key nursing skill, whether gathering the nursing history or performing the physical examination.Observation is the conscious and deliberate use of the five senses to gather data. Skilled nurses use each nurse–patient interaction to observe and to interpret meaningful stimuli (data). The nurse obtains a nursing history by interviewing the patient. An interview is a planned communication. Strong interviewing skills are needed to establish a successful working partnership with the patient, to communicate care and concern for the patient, and to obtain the necessary patient data. The interview can be understood in terms of its four phases, which include the preparatory phase, introduction,working phase, and termination. Physical assessment is the examination of the patient for objective data that may better define the patient’s condition and help the nurse in planning care. The physical assessment normally follows the nursing history and interview, and may verify data gathered during the history or yield new data. Unlike the physical assessment performed by the physician to identify pathologic conditions and their causes, the nursing physical assessment focuses primarily on the patient’s functional abilities. If a neurologic deficit is present, the nurse is concerned with identifying how this deficit affects the patient’s reasoning and sensorimotor abilities. For example,a patient who has had a cerebrovascular accident (brain attack or stroke) is examined to determine ability to comprehend and communicate information and execute the tasks of everyday life. Purposes of the nursing physical assessment include the appraisal of health status, the identification of health problems,and the establishment of a database for nursing intervention.
Obtain a nursing history using effective interviewing techniques
- Preparatory phase: Before initiating the interview, the nurse prepares to meet the patient by reading current and past records and reports,when available. During this phase, it is important not to let one’s stereotypes and prejudices affect the nurse–patient relationship. nurse should ensure that the environment in which the interview is to be conducted is private and relaxed. Both the seating arrangement and the distance between nurse and patient are important (Fig. 12-4). Chairs placed atright angles to each other and about 3 to 4 feet (0.9–1.2 m)apart facilitate an easy exchange of information. If the patient is in bed, placing a chair at a 45-degree angle to the bed is helpful. If the nurse stands at the foot or side of the patient bed and physically talks or looks down at the patient, a superior–inferior relationship is communicated and can negatively affect the interview. Whenever possible, it is best to communicate with patients at eye level.The interview should be scheduled when both the nurse and the patient are free of concerns and distractions so that they can concentrate on the task. Ten to 15 minutes may be all that is necessary in some circumstances, whereas an houror more may be required in others. Information can be gatheredin several meetings, especially if the nurse notices thatthe patient is tiring or is in pain.
- Introductory phase: nurse initiates the interview by stating his or her name and status, identifying the purpose of the interview, and clarifying the roles of nurse and patient.The initial impression the nurse creates is crucial, especially with patients who are new to the healthcare environment.All nurses whom the patient encounters in the future may be judged in light of this first impression. When the nurse communicates respect and genuine concern for the patient,the patient is then encouraged to discuss health concerns and problems freely. The competence and professionalism of the nurse as well as the interpersonal qualities of a respectful presence, professionalism, and caring invite the patient’s confidence and ensure the patient that help is available.During the introduction, the nurse should assess the patient’s comfort and ability to participate in the interview. It is also appropriate to assure the patient of confidentiality.The patient should know where the data being recorded are stored, how they will be used, and who has access to them.Some nurses record data on the appropriate form while with the patient, whereas other nurses take notes and complete the form later. Bedside computers are facilitating quick documentation.However, documenting data should not interfere with the sharing of information during the interview. In unusual situations in which a contractual agreement that clearly identifies the responsibilities of both patient and nurse is indicated (e.g., a gerontologic nurse entrepreneur),terms are discussed at this time.
- Working phase: nurse gathers all the information needed to form the subjective database.The accuracy, completeness, and relevance of the database depend on the nurse’s use of the interviewing and basic communication techniques. Many patient variables can positively or negatively affect the outcome of an interview, like high anxiety, pain, language difficulty, previous negative experience with other nurses or HC delivery system, and unrealistic expectations of HC professionals, unless the nurse responds appropriately.
- Termination Phase: The successful interview is concluded carefully. The nurse should advise the patient that the interview is coming to an end. It is helpful to recapitulate the interview, highlighting key points. Both the patient and the nurse should be satisfied that the important data are recorded. A helpful strategy is to ask the patient after the summary: “Is there anything else you would like us to know that will help us plan your care?” This gives the patient an opportunity to add data the nurse did not think to include.Before leaving the patient, it is helpful to alert the patient as to what he or she can expect. The patient should also know when the nurse will reestablish contact; for example,“Thank you for answering these questions, Miss LeBon. Please feel free to keep us informed of anything you think we should know. I’ll be leaving soon, but when I return tomorrow morning, I’ll discuss your plan of care. This afternoon will be busy for you—some blood tests and a chest x-ray have been ordered. Your evening will probably be quiet. Do you have any questions? Is there anything else I can do for you before I leave?”
Plan pt assessments by identifying assessment priorities and structuring the data to be collected systematically
Identify common problems encountered in data collection, noting their possible cause.
- - Database inappropriately organized, and the cause could be: Failure to plan for the assessment by identifying needed data; use of inappropriate tools for data collection.
- - Pertinent data omitted, and the cause could be: Not following up on cues during data collection; inappropriate guidelines
- - Irrelevant or duplicate data collected, and the cause could be: Failure to identify specific purpose of data collection; failure to review available patient records; use of inappropriate tools for data collection
- - Erroneous or misinterpreted data collection: Failure to observe carefully or validate during data collection; interviewer prejudices or stereotypes.
- - Failure to establish rapport: Failure to establish sufficient rapport or use appropriate communication techniques with patient; failure to know what information is wanted
- - Interpretation of data is recorded rather than the observed behavior: Nurse jumps to hasty conclusion about patient’s behavior and deprives others of exploring with the patient possible causes of the behavior; deficient validation
- - Failure to update the database: Erroneous belief that assessment is concluded after the initial database is recorded; low priority attached to ongoing data collection
Explain when data need to be validated and several ways to accomplish this.
Because validation of all data is neither possible nor necessary,nurses need to decide which items need verification. For example, data need to be verified when there are discrepancies:a patient tells the nurse he is fine and has no concerns, but the nurse notes that he demonstrates tense body musculature and seems curt in his responses. When there is a discrepancy between what the person is saying and what the nurse is observing, validation is necessary to determine accuracy. Validation in this instance may take the form of the nurse saying,“You tell me you feel fine, but right now your body and behaviors are telling me something else. Tell me more about this.” Data also need verification when they lack objectivity. For example, a nurse suspects that the patient hears in one ear but does not seem to hear well in the other. The nurse should validate the data before proceeding and should determine whether the patient does indeed have a hearing problem. Suspicions are not objective. In this instance, the nurse needs to test the patient’s hearing in both ears. Speaking toward the suspected better ear, the nurse explains, “It seems to me that you hear better out of one ear than the other. I would like to test this. I’ll bring a watch slowly toward your right ear first and then toward your left. Please look straight ahead and tell me when you first hear the watch ticking.” The nurse then records how far the watch was from each ear when the patient first heard it ticking. Nurses now use the language of cues and inferences to describe the process of validation. The subjective and objective data you identify (patient does not respond when I speak to him on his left side) is a cue that something may be wrong.The judgment you reach about the cue (the patient’s hearing may be impaired on his left side) is an inference. Until you check the patient’s hearing, you cannot be sure that your inferences correct.
- Inferences may be validated in multiple ways:
- • Physical examination, using the proper equipment and procedure (you may need to have an expert confirm your findings)
- • Clarifying statements (“You said this is not a problem,but I sense you may still be worried.”)
- • Sharing your inferences with other respected members of the team and seeking consensus
- • Checking your findings with research reports, textbooks,or journals
- • Comparing cues to knowledge base of normal function
- • Checking consistency of cues The nurse may validate data as they are collected or at the end of the data-gathering process. When it is clear that the data are correct, the nurse is ready to analyze the data and formulate nursing diagnoses—the next step of the nursing process.
Describe the importance of knowing when to report significant pt. data and of proper documentation.
The initial database should be entered into the computer or recorded in ink, using the designated agency forms, the same day the patient is admitted to the agency. If, for any reason,important data cannot be obtained during the initial assessment,this needs to be documented so that they are obtained as soon as possible. Objective and subjective patient data should be summarized and written so that data communicate a unique sense of the patient and are comprehensive, concise,and easily retrievable. The data should be written legibly,and good grammar and only standard medical abbreviations should be used. To facilitate quick data retrieval, data should be presented under clearly marked headings.Whenever possible, subjective data should be recorded using the patient’s own words. Quotation marks should be used: “I feel tired from the moment I first get up in the morning. Any more it seems I have no energy at all.” Patient reports may also be paraphrased: Patient reports feeling dyspneic, has difficulty catching breath when walking one flight of stairs.The tendency to record data using nonspecific terms that are subject to individual definition or interpretation—words like adequate, good, average, normal, poor, small, large—should be avoided. One nurse’s sense of what constitutes an average fluid intake may be very different from that of another nurse. It is important to be specific.
Obtain and document purposeful, complete, accurate, factual, and relevant pt. data
The purpose of obtaining a nursing history is to
Identify actual and potential nursing diagnoses. (The nursing history focuses on the pt's account of the actual or potential health problems and their impact on his or her health status, by the interview.)
After suffering a wrist fracture in a recent fall, a 77-year-old female
patient is strongly suspected of having osteoporosis. Which of the
following data best demonstrates the nursing focus of assessment?
A) The patient claims her mobility and independence have declined in recent years.
B) The patient demonstrates an unsteady gait and spinal kyphosis.
C) The patient's serum calcium levels are below the reference range.
D) The results of the patient's bone scan indicate decreased bone density.
A) The patient claims her mobility and independence have declined in recent years. (Nursing assessment focuses primarily on patients' responses to health problems, such as the effect of illness on activities of daily living, mobility, and independence. The patient's blood work, diagnostic results, and skeletal structure are relevant contributors to these considerations, but they are more indicative of a medical assessment framework.)
(this multiple choice question has been scrambled)
During the initial assessment of a newly admitted patient, the nurse has
clustered the patient's range of motion (ROM) with his gait, his bowel
sounds with his usual elimination pattern, and his chest sounds with his
respiratory rate. The nurse is most likely organizing assessment data
according to which of the following?
Body systems (The categorization of assessment findings according to systems (in this case, musculoskeletal, gastrointestinal, and respiratory) is characteristic of a body systems model for organizing data. While systematic, this strategy tends to ignore spiritual and psychosocial considerations.)
The nurse's morning assessment of an elderly patient has revealed some
anomalies. The nurse should document the patient's abnormal heart rate
as which of the following?
115 beats per minute (be specific in the charting)
During percussion, hands are used to strike the body surface and produce sound. Percussion is performed to determine density and hollowness and to discover location, level of organs, consistency of body structures, presence of tenderness, and identification of masses and tumors. (Nurse may do this to determine tenderness over the kidneys.)
A novice nurse collects data on a newly admitted patient. Upon
evaluation of these data, the nurse provides an erroneous
interpretation. What is a corrective action for this interpretation?
Encourage thenovice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward. (The novice nurse can improve interpretation skills by independently observing the same situation with a peer, comparing notes afterward, and role-playing various validation techniques.)
ANA Standards of Practice: Standard 1, Assessment
- Measurement Criteria
- The RN:
- - Collects data in a systematic and ongoing process.
- - Involves the pt, family, other HC providers, and environment, as appropriate, in holistic data collection
- - Prioritizes data collection activities based on the pt's immediate condition, or anticipated needs of the pt/situation
- - Uses appropriate EB assessment techniques and instruments in collecting pertinent data
- - Uses analytical models and problem-solving tools
- - Synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances
- - Documents relevant data in a retrievable format