Reviewer In Health Assessment PDF

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Summary

REVIEWER IN HEALTH ASSESSMENT(MIDTERMS)ASSESSMENT involves gathering data and information to make an informed diagnosis and developing a plan  demands good communication skills, observation skillsNURSING PROCESS first used/mentioned by Lydia Hall  5-step (ADPIE); now a 6-step process (ADOPIE)PRO...

Description

REVIEWER IN HEALTH ASSESSMENT



(MIDTERMS) ASSESSMENT 

involves gathering data and information to make an informed diagnosis and



For

referral,

utilize

SBAR

way

in

communicating patient’s condition



Includes the client’s perceived needs, health problems, related experiences,

demands good communication skills,

health practices, values and lifestyles.

observation skills

the assessment must be integrated into routine nursing care

 

first used/mentioned by Lydia Hall

information about the client): o

nursing health history

o

physical assessment

o

the physician’s history & physical

Humanistic care



Cyclic and Dynamic in nature

 

Involves skill in Decision-making

To provide nursing interventions

Time-lapsed assessment Reassessment

of

client’s

functional

tests

after initial assessment to compare the

o

material

from

other

health

Activities: COLLECTION OF DATA

Initial assessment assessment

client’s current status to baseline data previously obtained.

cultural beliefs/ norms

Validation of data- double-checking, cues, performed

specified time on admission

identified needs. 

threatening

results of laboratory & diagnostic

personnel



life

o

Client’s health status; his Actual/Present

To establish a plan of care to meet

identify

problems.



TYPES OF ASSESSMENT



to

status & circulation after a cardiac arrest.

PURPOSE OF NURSING PROCESS:

or needs.

Rapid assessment done during any

health pattern done several months

Uses Critical Thinking skills

and potential/possible health problems



Ex: assessment of a client’s airway, breathing

examination

o



Emergency assessment

client

5-step (ADPIE); now a 6-step process



earlier

& urine output hourly

To establish a data base (all the

(G O S H approach)

an

physiologic/physiologic crisis of the

(ADOPIE) PROBLEM SOLVING APPROACH

in

Ex: problem on urination-assess on fluid intake

PURPOSE OF ASSESSMENT 

identified

assessment

First Step in the Nursing Process 

use to determine status of a specific problem

ASSESSMENT

developing a plan

NURSING PROCESS

Problem-focused assessment

Ex: nursing admission assessment

within

a

Inferences. Organization of data - done systematically and according to priorities (ex. Maslow’s)

1

Analyzing of data - compare data against

Confirm patient statements to avoid



standard and identify significant cues Recording/documentation of data- (follow



COMMUNICATION STRATEGIES

Not written not done Types of Data:

SILENCE

Objective data - also referred to as Sign/Overt



data data

Symptom/Covert

-also data

referred Methods

to of

as

during

collected is accurate & complete. CONCLUSION 

pt. the opportunity to gather his encourages

the

pt.

questions

and

thoughts and make any pertinent final

to

continue”, “go on” and “uh-huh) CONFIRMATION

KINDS OF INTERVIEW QUESTIONS



Open-ended

questions Neutral question and Leading question

POINTS TO REMEMBER IN AN INTERVIEW Select a quiet private setting (time, place, seating arrangement, distance). Choose terms carefully and avoid using jargon. Use appropriate body language.

Ensures that both the nurses & the pt. are on the same track.

statements OBSERVATION EXAMINATION SOURCES OF DATA 

REFLECTION

Primary source – data directly gathered from the client using interview and physical examination.

(e.g. If I understand you correctly, you said…..)



Signals the pt. that the nurse is ready to conclude the interview. It provides the

continue with his story. (e.g. “please

Directive Interview and Nondirective

Closed

Facilitation

Restating the information that the pt. gave you. It ensures that the data

the

thoughts.



Interview



silence

FACILITATION

APPROACHES FOR INTERVIEW



 of

assess the client’s ability to organize

Data

INTERVIEW



SUMMARIZATION

talking & give a nurse a chance to

Collection



Nurse: What do you mean by I can’t stand this?

interview encourage the pt. to continue

Subjective



Moments

Is used when an information given is vague. E.g. client: I can’t stand this!

Use open-ended question.

guidelines in documentation)





misunderstanding.



Secondary source – data gathered from client’s family members, significant

Repeating something the pt. has just

others, client’s medical records/chart,

said can help you obtain more specific

other members of health team, and

information. CLARIFICATION

related care literature/journals. a 

Nursing Health History – a structured interview designed to collect specific

2

data and to obtain a detailed health 

Biographic data – name, address, age,

parameters.

Reason for visit/Chief complaint – primary

reason

why

client

seek







health



Nutritional - metabolic pattern

usual health status, chronological story,



Elimination pattern

family history, disability assessment.



Activity - exercise pattern

Past Health History – includes all



Sleep - rest pattern

previous



Cognitive - perceptual pattern

with illness.



Self-perception - concept pattern

Family History – reveals risk factors for



Role-relationship pattern

certain



Sexuality - reproductive pattern

immunizations,

disease

diseases

experiences

(Diabetes,



Coping - stress tolerance pattern



Is the problem statement that the nurse which

family

background, economic status, home

she

uses

to

communicate

3 activities in Diagnosing

Psychological data – information about

DIAGNOSING = Data Analysis + Problem

the client’s emotional state.

Identification + Formulation of NSG Diagnosis

Pattern of health care – includes all

= PES or PE

health care resources: hospitals, clinics, health centers, family doctors.





Problem statement/diagnostic label/definition = P

Risk

Nursing

diagnosis,

wellness,

Prioritize nursing diagnosis based on what problem endangers the client’s life.

PLANNING



utilize SMART in formulating goals, Life-threatening situations should be given highest priority



Consider the amount of time, materials, equipment required to care for clients.

professionally.

and neighbourhood conditions.



Potential Nursing diagnosis

METHODS for discharge planning

Social

relationships, ethnic and educational



Actual Nursing Diagnosis



NURSING DIAGNOSIS

makes regarding a client’s condition

include





daily living, recreation or hobbies. –

TYPES OF NURSING DIAGNOSIS

FORMULATE NURSING DIAGNOSIS

Lifestyle – include personal habits,

data

Defining characteristics/signs and symptoms

syndrome

Value - belief pattern

Review of systems – review of all

diets, sleep or rest patterns, activities of 

-

History of present Illness – includes:

health problems by body systems 

perception

management pattern.

hypertension, cancer, mental illness). 

Health

Etiology/related factors/causes = E

=S

GORDON’S FUNCTIONAL HEALTH PATTERNS

consultation or hospitalization. 

Developmental Level - group data and compare with normal developmental

sex, marital status, occupation, religion. 



record of a client

-Attend to client before equipment NURSING INTERVENTIONS 

Any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance client outcomes.



They are used to monitor health status; prevent, resolve or control a problem;

3

assist with activities of daily living; or promote

optimum

health



and

independence o

pattern, associated factors)

or collaborative measures.

Dependent Nsg. Intervention





Record actions – to complete nursing interventions, relevant documentation



Have you ever thought you should Cut down

Remember: Something that is

– those activities carried out on

NOT written is considered as

the order of a physician, under

NOT done at all.

Interdependent/Collaborative

severity,

CAGE questions:

should be done. o

duration,

onset,

these may be independent. Dependent

according to specific routines



Have you ever been annoyed by criticism of your drinking?



Have

you

ever

felt

Guilty

about

drinking?

EVALUATION



Purpose:

Do you ever have an Eye-opener o

YES to any of the above questions -

To appraise the extent to which

need to investigate further to see if

carries out in collaboration or

goals and outcome criteria of

there is a drinking problem

in relation with other members

nursing

of the health care team

achieved

– those activities the nurse





NCP

History

care of

have Present

been Illness

chronological story of what has 

It is the “blueprint” of the nursing process.

IMPLEMENTATION Activities: Reassessing – to ensure prompt attention to emerging problems.

REVIEW OF SYSTEMS (SUBJECTIVE HEAD-TOTOE REVIEW) 



General

-

recent

weight

change,

fatigue, fever

been happening

A written summary of the care that a client is to receive.



(character,

that the nurse is licensed to

a physician’s supervision, or



COLDSPA

Intervention – those activities

skills.





location,

nurse’s own knowledge and

o

folk)

carried out. Perform nursing interventions –

Independent Nsg.

initiate as a result of the

o

treatments - Rx, OTC, herbal,

Set priorities – to determine the order in which nursing interventions are

Must get details of the problem,



Skin – temperature, rashes, lesions,

therefore must be systematic

changes,

OLFQQAAT (one system – there

change, hair loss, change in hair or nails

are

others):

frequency,

onset, quality,

location,



factors, associated symptoms,

itching,

colour

Eyes - change in vision, floaters, glasses, pain, infections

quantity,

aggravating factors, alleviating

dryness,



Ears - pain, loss of hearing, vertigo, ringing, discharge, infections

treatments tried (include all

4

 

Neuro - fainting, blackouts, seizures,

Flatness – is an extremely dull sound

congestion, nosebleed

weakness, difficulty speaking, memory

produced by very dense tissue, such as muscle

Mouth and throat - condition of teeth

problems, general mood

or bone.

Nose and sinuses - frequent colds,

and sore throat





Endocrine - sweats, skin change, heat

Dullness – is a thud like sound produced by



Neck - lumps, stiffness, goiter

or cold intolerance, excessive thirst



Breasts - lumps, pain, discharge, BSE

(polydipsia), excessive urination

Respiratory - cough, sputum,

(polyuria), weight change, menstrual

Resonance – is a hollow sound with such as

wheezing, asthma, COPD, last PPD, last

changes

that produced by lungs filled with air.



CXR, smoking history (can do here, or





Cardiac - heart trouble, chest pain, SOB, murmur, h/o rheumatic fever, past EKG, FH of heart disease 2.2 lbs in 24 hours is



Duodenum

significant; indicates fluid loss or gain of



Gallbladder

1 liter)



Hepatic flexure of colon



Left kidney (lower pole)



Liver



Left ovary and tube



Pancreas (head)



Left ureter



Pylorus (the small bowel—or ileum—



Left spermatic cord

traverses



Sigmoid colon



all quadrants)



MIDLINE



Right adrenal gland



Bladder



Right kidney (upper pole)



Uterus



Right ureter



Prostate gland



Abdominal Wall Muscles

ABDOMINAL ASSESSMENT STRUCTURE AND FUNCTION 

The abdomen is bordered: superiorly by the costal margins, inferiorly by the symphysis pubis and inguinal canals, and laterally by the flank.

ABDOMINAL QUADRANTS 

The abdomen is divided into four quadrants for purposes of physical examination. o

right upper quadrant (RUQ),

o

right lower quadrant (RLQ),

o

left lower quadrant (LLQ), and

o

left upper quadrant (LUQ)

RIGHT LOWER QUADRANT (RLQ)

LEFT LOWER QUADRANT (LLQ)



Internal Anatomy



Appendix



(parietal peritoneum)



Ascending colon



(visceral peritoneum)



Cecum



Right kidney (lower pole)



Right ovary and tube



Right ureter



Right spermatic cord

LEFT UPPER QUADRANT (LUQ)

Collecting Subjective Data Interview Approach (COLDSPA) History

of

current

health

problem,

Associated Symptoms 

Indigestion, N&V, Diarrhea, (Stool)



Left adrenal gland



Constipation



Left kidney (upper pole)



Loss of Appetite and Weight Loss



Left ureter

Collecting Subjective Data

16

Q When does the pain occur (timing



Past Medical History



Family History



Lifestyle and health practices



Diet



Alcohol Use

(precipitating factors), make it worse



Stressors

(exacerbating factors), or make it better



Use



as eating, exercise, bedtime)? 

of

medications

(ASA,

NSAID,

Steroids)



Client preparation

Equipment and supplies: 



Q Do you experience indigestion? to

cause

or

aggravate

this

it

triggered

Q Have you ever had any of the gastrointestinal

inflammatory by

any

disorders:

gastroesophageal or

obstructive

reflux, bowel

disease, pancreatitis, gallbladder or liver disease, diverticulosis, or appendicitis

particular 

Q Have you had any urinary tract

Q Have you been vomiting? Describe

disease

the vomitus. Is it associated with any

disease or nephritis, or kidney stones 

such

as

infections,

kidney

Q Have you ever had viral hepatitis

Q Have you noticed a change in your

(type A, B, or C)? Have you ever been

of 1 to 10, with 10 being the worst?

appetite? Has this change affe...