Assessing - Assessment in nursing PDF

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Assessment in nursing...

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Assessing Assessment is the first phase in the nursing process - It is the systematic gathering of relevant and important patient data - Data are the information or facts about the patient used to o Identify health problems o Plan nursing care o Evaluate patient outcomes During the assessment phase, the nurse - Collects - Validates - Records - Organizes data into predetermined categories Standards of Practice - ANA outline nurse’s accountability for assessment - Adhering to these standards will help you collect data in a professional manner The purpose of the nursing assessment - To get a total picture of the patient and how they can be helped - Information obtained (data about patient, family, community patterns of health and illness, deviations from normal, strengths, coping abilities, and risk factors) 4 Steps 1. Collect data o Interview; information about family and community o Observation o Physical examination 2. Validate data with client and significant others o Compare subjective data with objective data o Validate conflicting data 3. Organize data o Initial assessment (admission data base) o Ongoing assessment (use nursing model to organize, document on care plan, or nursing process notes) o Special purpose assessments (perform as needed) 4. Record data Four Types of Nursing Assessments - Initial Comprehensive o Performed shortly after admittance to hospital o Performed to establish a complete database for problem identification and care planning

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o Performed by the nurse to collect data on all aspects of patient’s health Focused o May be performed during initial assessment or as routine ongoing data collection o Performed to gather data about a specific problem already identified, or to identify new or overlooked problems o Performed by the nurse to collect data about the specific problem Emergency o Performed when a physiologic or psychologic crisis presents o Performed to identify life-threatening problems o Performed by the nurse to gather data about the life-threatening problem Time-lapsed o Performed to compare a patient’s current status to baseline data obtained earlier o Performed to reassess health status and make necessary revisions in plan of care o Performed by the nurse to collect data about current health status of patient

Medical vs Nursing Assessment Medical Assessments - Target data pointing to pathologic conditions Nursing Assessments - Focus on the patient’s response to health problems

Three methods of collecting data are used in both comprehensive and focused nursing assessments 1. Observation 2. Physical examination 3. Interview

The Skill of Nursing Observation - Determines the patient’s current responses (physical and emotional) - Determines the patient’s current ability to manage care - Determines the immediate environment and its safety - Determines the larger environment (hospital or community) Observation is the conscious, deliberate use of the physical senses to gather data from the patient and the environment Develop a sequence of observation 1. As you enter the room, observe the patient for signs of distress (pallor, labored breathing, behaviors indicating pain or emotional distress) 2. Scan for safety hazards (are the side rails up, any spills)

3. Look at equipment (catheter, IV pumps, oxygen monitors). Is the equipment working? Do any alarms or screens indicate the need for immediate attention? 4. Scan the room (who is there and how do they interact with the patient) 5. Observe the patient more closely for data

Nursing History - Focuses on getting to know the patient - Clearly identifies patient’s strengths and weaknesses; health risks such as hereditary and environmental factors; potential and existing health problems Components of nursing history - Profile: name, age, sex, race/ethnicity, marital status, religion, education, occupation - Reason for seeking health - Normal health habits and patterns - Cultural considerations in relation to diet, decision making - Current state of health, functioning of body systems - Current medications, allergies, record of immunizations - Whether or not advanced directives exists, or if the patient wants help to prepare an advance directive - Patient’s personal resources (strengths and deficits) - Patient’s potential for injury - Perception of health status - Developmental history, family history, environmental history, psychosocial history - Patient’s and family’s expectation of nursing and of healthcare team - Patient’s and family’s education needs - Patient and family’s ability and willingness to participate in the plan of care Nursing interview During the initial assessment to obtain subjective data for nursing history - Purposeful, structured communication in which the nurse questions a patient to obtain subjective data - An admission interview is formal and planned - During ongoing assessments, interviews may be informal, brief, narrowly focused interactions between nurse and patient 4 Phases 1. Preparatory phase 2. Introduction 3. Working phase 4. Termination

Successful Interview Techniques - Focus on the patient during the interview - Listen to the patient attentively - Ask about patient’s main problem first - Pose questions and comments in appropriate manner - Avoid comments and questions that impede communication - Use silence and touch appropriately Types of Questions Used - Open-ended: allow patient to verbalize freely - Closed: elicit specific information - Validating: validate what is heard - Clarifying: avert misconceptions - Reflective: encourage patient to elaborate on thoughts and feelings - Sequencing: place events in chronological order - Directing: obtain more patient information Nursing Physical Assessment - Examination of the patient for objective data - May better define the patient’s condition - Helps the nurse in planning care - Follows the nursing history and interview - May verify data gathered during the history or yield new data - Focuses primarily on patient’s functional abilities Purpose of a Physical Assessment - Appraisal of health status - Identification of health problems - Establishment of a database for nursing intervention Problems Related to Data Collection - Inappropriate organization of the database - Omission of pertinent data - Inclusion of irrelevant or duplicate data, erroneous or misinterpreted data - Failure to establish rapport and partnership - Recording an interpretation of data rather than observed behavior - Failure to update the database When to Verify Data - When there is a discrepancy between what the person is saying and what the nurse is observing - When the data lack objectivity

Validating Inferences - Performing a physical examination using proper equipment and procedure - Using clarifying statements - Sharing inferences with other team members - Checking findings with research reports - Comparing cues to knowledge base of normal function - Checking consistency of cues (record cues not inferences)

One off the ANA standards require that data be documented in a retrievable format The nurse database becomes part of the patient’s permanent record

Documentation of Data - Immediately give verbal reporting of data whenever a critical change in the patient’s health status is assessed - Enter initial database into computer or record in ink on designated forms the same day patient is admitted - Summarize objective and subjective data in concise, comprehensive and easily retrievable manner - Use good grammar and standard medical abbreviations - Whenever possible, use patient’s own words - Avoid nonspecific terms subject to individual interpretation or definition...