Chapter 1 Nurse’s Role in Health Assessment Collecting and Analyzing Data PDF

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Summary

The history of nursing...

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Chapter 1 Nurse’s Role in Collecting and Analyzing Data

Health

Assessment:

Learning Objectives 1. Discuss how nursing assessment skills are needed for every situation the nurse encounters. a. As a nurse you will observe situations and collect info to make nursing judgments no matter whatthe setting. Professional nursing assessments you make on a client family or community determinenursing interventions that directly or indirectly influence their health status 2. Differentiate between a holistic nursing assessment and a physical medical assessment.

a. HOLISTIC- collects holistic subjective & objective data to determine overall level of functioning to make a nursing diagnosis i. The nurse assesses the physiologic, psychologic, sociocultural, developmental, & spiritual data about a client. ii. The mind, body, & spirit are interdependent factors. iii. The nurse focuses on how the client's health status affects ADLs, on how clients interact w/ their family/community, & how it affects them. b. Physical medical assessment i. focuses of physiological status ii. Less focus may be placed on psychological, sociocultural, or spiritual well-being. 3. Describe which phases of the nursing process involve assessment by the nurse. a. Assessment is ongoing and continuous throughout all phases of the nursing process; therefore all phases of the nursing process involve assessment. 4. List and describe the steps of the nursing process, explaining how some steps overlap and may have to be repeated many times when caring for a client.

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Assessment

Collecting subjective and objective data  Analyzing & synthesizing (combining) data  Making judgements about effectiveness of nursing interventions  Evaluating client care outcomes  Steps of HA: collect subj. data, collect obj. data, validate, & documentation. First & most critical phase If data is inaccurate, it may cause the nurse to make incorrect judgements, which can affect the remaining phases of the process. Assessment phase is ongoing & continuous throughout all the phases. Health assessment consists of health history & physical examination

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Diagnosis

Analyzing subjective and objective data to make a professional nursing judgment

(nursing diagnosis, collaborative problem, or referral) III

Planning

Determining outcome criteria and developing a plan

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Implementati Carrying out the plan on

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Evaluation

Assessing whether outcome criteria have been met and revising the plan as necessary

5. Describe the steps of the “analysis phase” of the nursing process. a. 7 major steps of data analysis i. Identify abnormal data & strengths ii. Cluster data iii. Draw inferences & identify probs. iv. Propose possible nursing dx v. Check the defining charac. Of dx vi. Confirm/rule out nursing dx vii. Document conclusions b. Purpose: arrive to a conclusion about client’s health at the ned of the assessment. c. Analyzing & stynthesizing data reveals if it’s a: i. Nursing concern: nursing diagnosis: a clinical judgement concerninga human response to health conditions ii. Collaborative problem: nurse implements physician & nurse prescribed interventions iii. Refferal: a Concern that needs to be reffered 1. Nurse uses a holistic assessment & identifies problems that require assistance from other HCM. 6. Compare and contrast the four basic types of nursing assessment: a. Initial comprehensive: collection of subj. & obj. data i. Ex: physical examination on a new pt b. Ongoing or partial: data collection after the comprehensive database is established. i. brief assessment used to detect new probs./ see if any problems got better/ worse ii. Ex: a pt who came to the clinic last week for the first time comes again to get checked a month later 1. partial assessment of a client admitted to the hospital w/ lung cancer requires frequent assessment of resp. rate, oxygen saturation & capillary refill. c. Focused/problem oriented: thorough assessement of a particular client prob. & does NOT address areas NOT r/t the prob. i. Ex: a pt tells you that they have ear pain, use COLDSPA to get more info about the are & you wouldn’t ask him questions that are not r/t the issue. d. Emergency: rapid assessment performed in life-threatning situations i. Ex: evaluating a pt’s ABCs when cardiac arrest is suspected. 7. Explain how the nurse’s role in assessment has changed over the past century. a. Today, nurse's not only use their physical senses to makes assessment, like it was used in the past century. The advancement of technology has allowed

the expansion of the nurse's assessment. Furthermore, the increased necessity of assessment skills b. Technology has changed/ health care system change over years c. Nurse’s make independent interventions that they are responsible for. 8. Describe what the nurse’s role in assessment may be 25 years from now. a. There will be an increase in specialization & diversity of assessment skills for nurses. As technology advances & patient acuity, & health challenges, will involve the need for nurse's to use assessment skills. 9. 4 major steps of the assesemnt phase a. Collection of subjective data- subjective data are sensations/symptoms(ex: pain/hunger) feelings (ex: happiness/sadness) perceptions, desires, personal info, etc. that can verified by the patient i. Major areas of S.D1. Biographical info (name, age, occupation, religion) 2. History of present health concern 3. Personal health history 4. Fam. History 5. Health & lifestyle 6. Review of systems b. Collection of objective data- examiner directly observes objective data i. Inc.: 1. Physical characteristics (skin color/posture) 2. Body func. (heart/respiratory rate) 3. Appearance (dress/hygiene) 4. Behavior (mood/affect) 5. Measurements (BP/temp/weight/height) 6. Lab results ii. This type of data is obtained by general observation & the 4 physical examination techniques: 1. inspection, palpitation, percussion, & auscultation. 2. Also, by medical/health records & observations noted by fam. Of the client c. Validation of data - CRUCIAL PART OF ASSESSMENT i. Often happens w/ collection of subjective & objective date ii. Serves to ensure that assessment process isn't completed before ALL RELEVANT data is collected. This helps prevent inaccurate data d. Documentation of data- forms the database for the entire nursing process & provides data for all other membs. Of the health care team. i. Accurate documentation is VITAL bc it ensures that valid conclusions are made. Definitions  Nursingo the protection, promotion, & optimization of health & abilities, prevention of illness & injury, o Alleviation of suffering through the diagnosis & treatment of human responses & advocacy in the care of indvs. Families, communities, & populations  Acuity- measurement of the intensity of nursing care that is required by a patient  Holistic- treatment of a WHOLE person, by taking into account mental & social factors, not just the symptoms of a disease/  Holistic data collection- the collection of physiological, sociocultural, developmental, & spiritual data of the client  ADL- Activities of daily living  Assessment- according to the ANA this is the collection by the RN of comprehensive data pertinent to the patient's health/ situation

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Elicited- evoke/draw out (usually a response)...