Chapter 16 Assessment - LECTURE NOTES PDF

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Summary

LECTURE NOTES...

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Key Points Assessment

Nursing assessment involves two steps: Types of Assessments

Notes  learn as much as you can about each patient’s health condition and health problems by partnering with the patient and family caregivers in a therapeutic relationship.  you collect a comprehensive set of data about a patient and recognize and identify patterns that begin to reflect the meaning of a patient’s response to health problems  ultimate goal in assessment is to gather all of the information necessary to reveal a patient’s health care needs. • Collection of information from a primary source (a patient) and secondary sources (e.g., family caregiver, family members or friends, health professionals, medical record). • The interpretation and validation of data to determine whether more data are needed, or the database is complete. • Patient-centered interview (conducted during a nursing history) • Periodic assessments (conducted during ongoing contact with patients)

Gordon’s 11 functional health patterns ABCDE

• Physical examination (conducted during a nursing history and at any time a patient presents a symptom)  health perception and management, nutritional-metabolic, elimination, activity-exercise, sleeprest, cognitive-perceptual, self-concept, role-relationship, sexuality-reproduction, coping-stress tolerance, and value-beliefs.  Airway  Breathing  Circulation  Disability  Exposure

Example of ProblemFocused Patient Assessment: Pain

Patient symptoms such as pain, shortness of breath, or nausea will direct you to examine various bodily functions Example: shortness of breath: lung sounds and chest excursion nausea: bowel sounds, abdominal distention  Subjective data are your patients’ verbal descriptions of their health problems. Subjective data include patient feelings, perceptions, and self-reported symptoms.  Objective data are the findings resulting from direct observation or measurement, including what you see, hear, and touch. Inspecting the condition of a wound, observing a patient walk 

Types of Data

Assessment Data Sources

I-PASS Handoff The NursePatient Relationship in Assessment patient-centered interview

Motivational interviewing

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Interview Preparation Phases of the Interview

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Collecting Data

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down the floor, measuring blood pressure, and describing specifically an observed behavior (patient seizure) are examples of objective data Patient Family Caregivers and Significant Others Health Care Team Medical Records Other Records and the Scientific Literature (Educational, military, and employment records often contain significant data about a patient (e.g., immunizations, prior illnesses). If a patient received services at a community clinic or a different hospital, you need written permission from the patient or guardian to access the record. The HIPAA regulations protect access) Nurse’s Experience Illness severity, Patient summary, Action list, Situation awareness and contingency plans, and Synthesis by receiver Only to understand a patient is insufficient; the nurse must also convey the message that the patient is understandable and acceptable

The most extensive patient-centered interview is the one used during collection of a nursing history. Primary objectives while taking an initial nursing history are to discover details about a patient’s concerns, explore expectations for the health care visit, and display genuine interest and partnership. It is a technique used often in counseling and patient education that allows you to become a helper in the change process. Motivational interviewing addresses a patient’s ambivalence or uncertainty about following medically indicated behavioral changes and supports patients in making health care decisions in cases in which there is more than one reasonable option Communication Skills (Courtesy, Comfort, Connection, Confirmation) Orientation and Setting an Agenda (Introduce and set the tone of the visit like to determine the diagnosis of illness) Working Phase—Collecting Data Termination Phase (summarize your discussion with a patient and check for accuracy of the information you collected during the termination phase of an interview. End the interview in a friendly manner, telling the patient when you will return to provide care. Let your patient know when the interview is coming to an end. For example, say, “I have just two more questions. We’ll be finished in a few more minutes.”) Interview Techniques (Because a patient’s report will contain subjective information, validate subjective data later with objective information. For example, if a patient reports difficulty breathing, you will further assess the patient’s respiratory rate and lungs sounds during the physical examination) Observation Open-Ended Questions (For example, “So, tell me more about ….” or “What are your concerns about this?” or “Tell me how you have been feeling.”) Direct Closed-Ended Questions (Formulate good closed-ended questions. This technique requires short answers and clarifies previous information to provide a more comprehensive database. The questions do not encourage patients to volunteer more information than you request.) Leading Questions (These types of interview questions are risky because they can limit the information a patient will provide to what a patient thinks you want to know) (Two examples of leading questions are (1) “It seems to me this is bothering you quite a bit. Is that true?” and (2) “That wasn’t very hard to do, was it?” or When asking how often a symptom or problem

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occurs, allow a patient to define “often.” Do not ask, “It didn’t happen too often, did it?”) Back Channeling (active listening prompts such as “all right,” “go on,” or “uh-huh”) Probing (encourage a full description without trying to control the story’s direction. such as “Is there anything else you can tell me?” or “What else is bothering you?”) during an initial or early contact with a patient. The history is a key component of your comprehensive assessment. Most health history forms (electronic and manual) are structured. However, on the basis of information you gain as you conduct the patient-centered interview, you learn which components of the history to explore fully and which require less detail.

Health History

Considerations in history taking / Assessment Components of the Nursing Health History

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Cultural Considerations Professionalism in History Taking

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Biographical Information Chief Concern or Reason for Seeking Health Care Patient Expectations Present Illness or Health Concerns (PQRST – Provokes, Quality, Radiate, Severity, Time) Past Health History Family History Psychosocial History Spiritual Health

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Data Documentation

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  The Assessment Process

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Review of Systems (systematic approach for collecting subjective information from patients about the presence or absence of health-related issues in each body system) Observation of Patient Behavior Diagnostic and Laboratory Data clear, concise manner using appropriate terminology. This information becomes the baseline to identify a patient’s nursing diagnoses and health problems, to plan and implement care, and to evaluate a patient’s response to interventions. If you do not record an assessment finding or a suspected problem, it is lost and unavailable to anyone else caring for the patient. If information is not specific, the reader is left with only general impressions. Observing and recording patient status are legal and professional responsibilities for all nurses. When recording data, pay attention to facts, and be as descriptive as possible. Record objective information in accurate terminology (e.g., weighs 77.2 kg [170 lb], abdomen is soft and nontender to palpation) Record any subjective information by using quotation marks. Data Collection Validation Interpretation

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