NUR1010 Nursing Process: Assessment

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NUR1010 Nursing Process: Assessment
2014-03-01 11:43:09
NUR1010 Nursing Process Assessment

NUR1010, Nursing Process: Assessment
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  1. assessment includes which 4 features
    • -collecting data
    • -categorizing data
    • -recording data
    • -it should be a systematic and ongoing process

    • it is the systematic gathering of data related to the
    • -physical
    • -mental
    • -spiritual
    • -socioeconomic
    • -cultural status

    • facts, impressions, contextual information
    • of an individual, group, or community
  2. what is the purpose of the assessment
    -to obtain enough data to allow the nurse to help the patient

    -the assessment becomes part of the patient database

    - tool to develop a plan of care
  3. how is the assessment related to diagnosis
    assessment provides data needed for identifying client's actual /potential health problems and strengths
  4. how is the assessment related to the planning outcomes
    the data about the patient's family, motivation, avail.resources ... helps to find realistic goals
  5. how is the assessment related to planning interventions ?
    collected data help to choose the interventions that are most likely to be accepted and effective for the patient
  6. how is the assessment related to the implementation
    while observing the client's response there can be additional data be observed. this additional data might lead to a new diagnosis (e.g. acitvity intolarance )
  7. how does nursing assessment fit into collaborative care?
    • nurse-> focus o n client's responses to illness
    • - physical resonse
    • -understanding of illness
    • -how it affects their lives
    • emotional response and concerns

    • healthy client
    • -how maintain current level of wellness
    • - how prevent disease

    • other health professionals can access database with assessment findings from nurse
    • evtl. delegation or referral after assessment
  8. professional standards about assessment
    • -complete
    • -skillful
    • -timely

    • Joint Commission
    • -written, comprehensive (physical, psychological, social-> to identify priority)
    • different policies regarding reassessment

    if assessment should be done by RN, he/she cannot delegate it (parts like height and weight can be delegated)

    -all patients are assessed for pain
  9. Sources of data

    subjective data
    subjective/ covert date, symptoms

    • communicated to the nurse from client of family ...
    • reveal perspective of the person giving the data including thoughts, feelings, beliefs, sensations

    can be used to clarify objective data

    some people are unable to provide subjective data (infants, ...) or accuracy is questioned

    double checking of subjective data is sometimes useful
  10. sources of data

    objective data
    objective data/ overt data, signs

    gathered through physical assessment, from laboratory, diagnostic tests

    can be measured and observed e.g. vital signs, x=ray, urine output, skin color,...

    also used to check objective data

    checking for risk factors after subjective data has been gathered
  11. primary data vs. secondary data
    primary data: directly heard from client or directly assessed

    secondary data: obtained "second hand" from medical record, ....
  12. types of assessment:

    initial or ongoing
    initial and ongoing (first obtain data fpr patient's reason for visit, then comprehensive if possible)-> guidance of care, further assessment, data tend to be static, not likely to change often

    • ongoing
    • performed as needed, any time after initial-> to identify new problems, follow up existing problems (status), sees dynamic state of client, e.g. vital signs as indicator of development or resolvation of health problems
  13. types of assessment:

    comprehensive vs. focused
    comprehensive assessment/ global assessment/ patient database/ nursing database: holistic information about the client's overall health status (bodysystems, abilities, emotional, spiritual, psychosocial status including family and community -> identify strengths + problems, culture, values, beliefs, economic situation

    • focused -> obtain data about actual, potential, possible problem identified/suspected
    • e.g. pain, nutrition, spiritual health, social support, lifestyle, family
    • added to data from comprehensive assessment

    initial focused <->ongoing focused
  14. special needs assessment
    • is a type of focused assessment
    • provides in-depth information about particular area
    • some are required (e.g. nutrition and pain)
    • some required regarding area (rehabilitation-> functional abilities)
    • balance to not intrude client's privacy
  15. nutritional assessment
    • related to personal, psychosocial, economic
  16. pain assessment
    on all clients during initial assessment and in ongoing assessments
  17. functional ability assessment
    • decline in functional status?
    • important in discharge planning/ home care
    • rehabilitation needs ? -> see initial + ongoing functional ability status
    • Joint Commission: appropriate for every guest
  18. 3 assessment tools of functional assessment
    • The Katz Index of ADL scale
    • best for performance in basic areas
    • 1 point for independence in
    • -bathing
    • -toileting
    • -dressing
    • -transfer
    • -continence
    • -feeding

    • Lawton Instrumental Activities of Daily Living (IADL)
    • easy to use
    • assesses more challenging tasks like shopping
    • useful for older adults -functional decline in 48 hours?

    • The Karnofsky Performance Scale
    • used in palliative care/ end of life
  19. cultural assessment
    • awareness of cultural influence
    • do not stereotype
    • assess and honor diversity of clients
  20. spiritual heath assessment
    • contributes to overall well being
    • source of support
    • more than just asking -> how does client interpret life events and health
  21. psychosocial assessment
    to be performed more focused if indication that social/ emotional (e.g. anxiety) are not met or sociocultural factors (unemployment)

    • lifestyle,
    • coping patterns
    • understanding of current illness
    • personality
    • previous psychiatric disorders
    • mental status
  22. wellness assessment
    • health promotion focuses on
    • activities to achieve higher level of health
    • most assessment tools are self-administered
    • spiritual halth
    • social support
    • nutrition
    • physical fitness
    • health beliefs
    • lifestyle
    • life stress review
  23. family assessment
    • behavior and beliefs usually start in family
    • -> this assessment might provide better understanding of values, beliefs, behavior
  24. community assessment
  25. community assessment
    • information about
    • demographics
    • resources
    • health concerns
    • points of referral
    • environmental risks,
    • community norms and values
  26. What is included in a Comprehensive Assessment?
    • consists of nursing history and physical examination
    • it contains objective and subjective data
    • first: initial comprehensive assessment = database
    • collection of data through all senses
    • observation, physical examination and interviewing
  27. observation
    • use of all senses to gather and interpret information
    • try to use same sequences of observation at each patient contact
    • the more observation the less likely to miss an assessment data
  28. physical assessment/ physical examination
    • primarily objective data
    • inspection
    • palpation
    • percussion
    • auscultation
  29. nursing interview
    • purposeful, structured communication with patient (questions) to obtain subjective data for the nursing database
    • admission interview is planned
    • during ongoing assessment interview may be informal, brief, focused
  30. biographical data
    • unchanging information name, dob, gender, race,religion, occupation, marital status
    • response reflect mental status and ability to communicate
  31. components of a nursing health history
    • biographical data
    • chief complaint/ reason for seeking healthcare
    • history of present illness
    • clients perception of health status and expectations for care
    • past health history
    • family health history
    • social history
    • medication (nutritional supplements, herbs) history and device use
    • complementary/ alternative modalities (CAM)
    • review of body systems and associated functional abilities
  32. chief complaint/ reason for seeking health care
    • What brings you to the hospital today?
    • document client's response in his own words
    • follow up be asking specifically what caused...
  33. history of present illness
    • in-depth exploration of chief complaint
    • when illness/ problem began
    • onset sudden or gradual
    • how often
    • what does make it worse
    • what to do to relieve it
    • how has clients health changed from usual status
    • effect on daily life
  34. clients perception of health status and expectation
    • knowledge about illness
    • what does the client expect to be done for him
    • what does the cient want the nurses to do to help
  35. past health history/ medical history
    • childhood diseases
    • immunizations
    • previous hospitalizations, surgeries

    -> helps to guide assessment, helps to understand data
  36. family health history
    • data of first degree blood relatives (mother , father , siblings, maternal and paternal grandparents)
    • diseases, current state of health, alive or dead, cause of death, -> risk factors?
  37. social history
    • information about
    • family and other relationships,
    • economic status
    • occupations
    • exposure to toxic materials
    • home and neighborhood conditions
    • ethnicity
    • tobacco, alcohol, drug use
    • exercise habits
  38. medication history and device use
    • past and current medication usage (also uncover medical history) -> interaction of meds? effecting body symptoms/ abnormalities?
    • previous episodes of medical treatment and devices, braces, inhalers, ..
    • vitamins, nutritional supplements, alternative therapy medications (herbs)
  39. complementary/alternative modalities (CAM)
    • therapies used instead or in addition to recommended one from physician
    • e.g. chiropractic carem homeopathy, aromatherapy, music therapy, massage therapy, energy work, acupressure, acupuncture -> can support or interfere with conventional therapies!
  40. review of body systems and associated functional abilities
    • subjective data regarding body systems (e.g. productive cough?)
    • includes functional abilities (dressing, bathing,..)
    • can be obtained during physical assessment or in interview
  41. types of interviews
    • directive
    • factual, easily categorized information, emergency situation
    • control of topics , mostly closed questions
    • who, when, where,...
    • useful for anxious client or communication difficulties

    • non directive interviewing
    • promote communication, build rapport, help express feelings
    • open ended question
    • subjective data
    • what is important for client
    • time consuming, much irrelevant data
  42. preparing for the interview
    • be sure to tell that given information will be kept confidential
    • right to refuse to answer
    • client might have a need to talk about a topic and is relieved when it is brought up
    • afraid to upset patient? -> usually reliefed after expressing emotions, learn to accept expression of strong emotions
    • do not avoid difficult topics (gaps)-> patient will not get help they need
    • prepare yourself and patient before asking questions
  43. how and when to validate data
    • obtaining abnormal reading ->
    • ask more questions
    • ask another nurse to double check your findings
    • check when measure device was last calibrated
    • retake measurement
    • compare readings to previous findings
    • check on another bodypart
    • wait some time before re checking

    -> to ensure if data is acurate, complete, factual, to avoid to jump into conclusions
  44. under which circumstances should data be validated?
    subjective and objective data do not agree/ do not make sense together

    the clients statements differ at different times of the interview

    data fall far outside normal range

    factors are present that interfere with accurate measurement
  45. how can data be organized ?
    • professional standards require systematic data collection->
    • collect and record date in predetermined categories
    • initial assessment: agencie's data collection form
    • ongoing assessment: may need to use own organizing structure/ framework
    • a framework represents way of thinking and shows which information is significant and guides decision(s)-> help to find clusters and patterns
  46. nonnursing models
    • most agencies use a body systems (MEDICAL) framework for at least a section of the assessment form
    • holistic data: identify both medical and nursing problems

    • Maslow's Hierarchy of needs
    • 1 Physioligical
    • safety and security
    • love and belonging
    • esteem and self esteem
    • cognitive (knowledge , understanding..)
    • aesthetic (symmetry, order , beauty)
    • self actualization (acieve one's potential, growth...)
  47. How should data be documented?
    • retrievable format
    • accurate, timely, clear
    • documentation protects health professionals
    • if it isn't documented, it wasn't done
  48. guidelines for recording assessment data
    • document asap after assessment
    • write neatly, legibly, in black ink
    • acronyms sparingly, agency approved abbreviations
    • write patients own words if possible, quotation marks, too long: summarize
    • record only most important words
    • concrete, specific information
    • record cues (said, observed) rather than inferences (judgements, interpretations) do not use appears or seems.
  49. cial p
  50. tools for recording assessment data
    • graphis flow sheet
    • vitals
    • trends can be seen clearly

    • intake and output sheet
    • graphic sheet, spaces for all intake> oral, intravenous, tube feedings,...
    • and all output like drainage, bowel movements,...

    nursing admission assessment

    • nursing discharge summary
    • can be part of initial assessment form

    special-purpose form e.g. diabetic flow sheets

    • computer documentation
    • easily shareable