CHAPTER 14: Assessing

Once you have organized (clustered) your data according to the purpose of your assessment, you look for and test your A A about patterns of human functioning.

initial impressions

The nurse may also perform a nursing physical examination to collect data. The nursing physical assessment involves the examination of all body systems, review of systems (ROS), in a systematic manner, commonly using a head-to-toe format. Four methods are used to collect data during a physical assessment: PE is Inspired patting patient audibly

inspection, palpation, percussion, and auscultation.

Common problems in data collection include 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 with the patient, recording an A of data rather than B behavior, and failure to update the database.

interpretation, observed

Objective 2: Explain the relationship between nursing assessment and medical assessment.

nursing: to care --> gather/collect, analyze, validate, communicate, focus on human response to disease medical: to diagnose, treat, cure

Objective 3: Differentiate between objective and subjective data.

obj: things I can see: vitals, signs subjective: what the pt reports (C/c, sx) cannot be verified

Objective 6: Obtain a nursing history using effective interviewing techniques.

open-ended build trust ensure privacy active listening ask about main issue first

Objective 10: Describe privacy, confidentiality, and professionalism issues related to patient assessment and data storage.

our primary ethical responsibility

Objective 4: Identify five sources of patient data useful to the nurse.

Patient is best source. other sources: family, significant other, pt record, assessment literature, other healthcare professionals

To enable sound clinical reasoning, nursing assessments should have these 7 characteristics: PPCSARR

Peter Pan can secretly act real rough. Purposeful Prioritized Complete Systematic Accurate Relevant Recorded

Read the following scenario and identify the adjective used to describe the characteristics of patient data that are numbered below. Place your answers on the lines provided. The nurse is conducting an initial assessment of a 79-year-old female patient admitted to the hospital with a diagnosis of dehydration. The nurse (1) uses clinical reasoning to identify the need to perform a comprehensive assessment and gather the appropriate patient data. (2) First the nurse asks the patient about the most important details leading up to her diagnosis. Then the nurse (3) collects as much information as possible to understand the patient's health problems; (4) collects the patient data in an organized manner; (5) verifies that the data obtained is pertinent to the patient care plan; (6) records the data according to facility's policy.

(1) Purposeful: The nurse identifies the purpose of the nursing assessment (comprehensive) and gathers the appropriate data. (2) Prioritized: The nurse gets the most important information first. (3) Complete: The nurse gathers as much data as possible to understand the patient health problem and develop a care plan. (4) Systematic: The nurse gathers the information in an organized manner. (5) Accurate and relevant: The nurse verifies that the information is reliable. (6) Recorded in a standard format: The nurse records the data according to the facility's policy so that all caregivers can easily access what is learned.

Which statement is true regarding addressing a priority problem? A priority problem requires a nursing intervention before another problem is addressed. OR The priority of problems is established and continued according to the nursing plan of care.

A priority problem requires a nursing intervention before another problem is addressed. rationale: A priority problem requires a nursing intervention before another problem is addressed, but addressing priority problems does not entail skipping any interventions. The priority of problems can change as a client's condition changes. There are no predetermined times or intervals at which to identify priority problems. This is why critical thinking plays a central role in nursing.

An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates the nurse is an effective caregiver? The nurse leaves the room when a client is crying to provide privacy. OR The nurse uses open-ended questions when working with a crying client.

Answer: The nurse uses open-ended questions when working with a crying client. Any nurse who wishes to be an effective caregiver must first learn how to be an effective communicator. Good communication skills enable nurses to get to know their clients and, ultimately, to diagnose and to meet their needs for nursing care. By asking open-ended questions the nurse can gain more information as to why the client is crying. Without understanding the "why" behind the crying the nurse cannot determine if the hospital chaplain might be needed. Providing privacy for the client can be thoughtful but not a way to learn more.

4 Nursing assessments include the CI-FET

Comprehensive Initial assessment Focused assessment Emergency assessment, Time-lapsed assessment.

Objective 1: Define and describe the purpose of five types of nursing assessments.

Focused - to gather info about specific problem or new problem Time-lapsed - trend more than one visit/find changes Emergency - life threats (ABCs) Initial - complete databased for problem identification or care plan

Objective 12: Obtain and document purposeful, prioritized, complete, systematic, accurate, and relevant patient data in a standard format.

This is how a nursing assessment should be 1) Prepare (select priorities, assessment type) 2) collect data (observe, interview, exam) 3) Validate (Clarify, double-check) 4) Organize (Document, Maslow's hierarchy)

focused assessment:

assessment is conducted to assess a specific problem; focuses on pertinent history and body regions but may also be used to address the immediate and highest priority concerns for an individual patient

nursing history:

assessment of the patient by interview to identify the patient's health status, strengths, health problems, health risks, and need for nursing care

A is the act of confirming or verifying. The purpose of validating is to keep data as free from error, bias, and misinterpretation as possible. This is an important part of assessment because invalid information can lead to inappropriate nursing care.

Validation

The nurse collects objective and subjective data when conducting patient assessments. Which patient situations are examples of subjective data? Select all that apply. A) A patient tells the nurse that she is feeling nauseous. B) A patient's ankles are swollen. C) A patient tells the nurse that she is nervous about her test results. D) A patient complains that the skin on her arms is tingling. E) A patient rates his pain as a 7 on a scale of 1 to 10. F) A patient vomits after eating supper.

a, c, d, e. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, tingling, and experiencing pain. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Examples of objective data are an elevated temperature reading (e.g., 101°F), edema, and vomiting.

The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply. A."The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." B. "It's hospital policy. I know it must be tiresome, but I will try to make this quick!" C."I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care." D. "We want to make sure that your responses to the medical exam are consistent and that all our data are accurate." E."We need to check your health status and see what kind of nursing care you may need." F."We need to see if you require a referral to a physician or other health care professional."

a, e, f. Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient's responses to health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgment about a patient's health status, the ability to manage his or her own health care and the need for nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on the patient's strengths and promotes optimum functioning, independence, and well-being, and enables the nurse to refer the patient to a physician or other health care professional, if indicated. The fact that this is hospital policy is a secondary reason, and although it may be true that a nurse may need to develop assessment skills, it is not the chief reason the nurse performs a nursing history and exam. The assessment is not performed to check the accuracy of the medical examination.

When preparing for data collection, establishing A A and B B data collection are two important considerations. The purpose of the assessment offers the best guideline about what type and how much data to collect. Assessment priorities are influenced by the patient's health orientation, developmental stage, culture, and need for nursing.

assessment priorities, sytematically structuring

A student nurse tells the instructor that a patient is fine and has "no complaints." What would be the instructor's best response? (A) "You made an inference that she is fine because she has no complaints. How did you validate this?" (B) "She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship." (C) "Sometimes everyone gets lucky. Why don't you try to help another patient?" (D) "Maybe you should reassess the patient. She has to have a problem—why else would she be here?"

a. The instructor is most likely to challenge the inference that the patient is "fine" simply because she is telling you that she has no problems. It is appropriate for the instructor to ask how the student nurse validated this inference. Jumping to the conclusion that the patient does not trust the student nurse is premature and is an invalidated inference. Answer c is wrong because it accepts the invalidated inference. Answer d is wrong because it is possible that the condition is resolving.

time-lapsed assessment:

an assessment that is scheduled to compare a patient's current status to baseline data obtained earlier

A nurse is performing an initial comprehensive assessment of a patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following? (A) Maslow's human needs (B) Gordon's functional health patterns (C) Human response patterns (D) Body system model

b. Gordon's functional health patterns begin with the patient's perception of health and well-being and progress to data about nutritional-metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow's model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems.

A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor's best reply? A "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!" B"You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." C"No one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh with each new patient." D"Don't worry about learning all of the questions to ask. Every facility has its own assessment form you must use."

b. Once a nurse learns what constitutes the minimum data set, it can be adapted to any patient situation. It is not true that each assessment is the same even when using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person-centered practice tailor their questions to the uniqueness of each patient and situation. Answer d is incorrect because relying solely on standard facility assessment tools does not allow for individualized patient care or critical thinking.

The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action? (A) Inform the charge nurse. (B) Inform the surgeon. (C) Validate the finding. (D) Document the finding.

c. The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse should be sure that all data recorded are accurate; thus, all data should be validated before documentation if there are any doubts about accuracy.

There are two types of data: subjective and objective. Subjective data are information perceived only by the affected person; these data A be perceived or verified by another person. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them.

cannot

The patient data collected by the nurse, both initially and as patient contact continues, are of no benefit to the patient and the health care team unless they are appropriately A. This involves correct B and proper C.

communicated, timing, documentation

initial assessment:

comprehensive nursing assessment resulting in baseline data that enable the nurse to make a judgment about a patient's health status, ability to manage one's own health care, and need for nursing, and to plan individualized, holistic health care for the patient

Observation is a key nursing skill, whether gathering the nursing history or performing the physical examination. Observation is the A and deliberate use of the B senses to gather data.

conscious, 5

Objective 11: Describe the importance of knowing when to report significant patient data and of proper documentation.

critical change in pt's health --> verbalize immediately

Since the entire nursing process rests on the initial and ongoing assessment of the patient, it is imperative to use excellent A A and B B skills when gathering, analyzing, validating, and communicating data.

critical thinking, clinical reasoning

Nurses now use the language of cues and inferences to describe the early analysis of data. The collective subjective and objective data you identify is a A that something may be wrong. The judgment you reach about the cue is an B

cue, inference

The A is the primary and usually the best source of information. Unless specified otherwise, it is assumed that the data recorded in the nursing history were collected from the patient. Other sources of information include family and significant others, the patient record, B B, other health care professionals, and the nursing and other literature.

patient, assessment technology

A nurse notes that a shift report states that a patient has no special skin care needs. The nurse is surprised to observe reddened areas over bony prominences during the patient bath. What nursing action is appropriate? a. Correct the initial assessment form. b. Redo the initial assessment and document current findings. c. Conduct and document an emergency assessment. d.Perform and document a focused assessment of skin integrity.

d. Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone or corrected. This is not a life-threatening event; therefore, there is no need for an emergency assessment.

The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? A. Comprehensive B. Initial C. Time-lapsed D. Quick priority

d. Quick priority assessments (QPAs) are short, focused, prioritized assessments nurses do to gain the most important information they need to have first. The comprehensive initial assessment is performed shortly after the patient is admitted to a health care facility or service. The time-lapsed assessment is scheduled to compare a patient's current status to baseline data obtained earlier.

When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. After introducing herself to the patient and his wife, what should the nurse do? (A) Thank the wife for being present. (B) Ask the wife if she wants to remain. (C) Ask the wife to leave. (D)Ask the patient if he would like the wife to stay.

d. The patient has the right to indicate whom he would like to be present for the nursing history and exam. The nurse should neither presume that he wants his wife there nor that he does not want her there. Similarly, the choice belongs to the patient, not the wife.

Objective 5: Describe the purpose of nursing observation, interview, and physical assessment.

history: identify pt's health status, problems, risks, strengths, need for care interview: planned communication w/4 phases (prep, intro, working, termination) exam: to collect data, includes body systems ROS --> inspection, palpation, percussion, auscultate observation: use of 5 senses to gather data during the hx and exam

Objective 8: Identify common problems encountered in data collection, noting their possible causes.

inappropriate organization of database -> failure to plan for assessment and needed tools omission of pertinent data - not f/u on cues inclusion of irrelevant data --> failure to identify purpose of data misinterpreted data failure to update database

Maslow's Hierarchy of Needs •Self-actualization needs are fifth-level needs. •Self-esteem needs are fourth-level needs. •Love and belonging needs are third-level needs. •Safety and security needs are second-level needs. •Physiological needs are first-level needs.

physical, safety and security, love and belonging, self-esteem, self-actualization

Assessing is the A and continuous collection, analysis, validation, and communication of B data, or information. These data reflect how health functioning is C by health promotion or D by illness and injury. A E includes all the pertinent patient information collected by the nurse and other health care professionals.

systematic, patient, enhanced, compromised, database

inference:

the judgment reached about a cue

The nursing history identifies the patient's health status, strengths, health problems, health risks, and need for nursing care. The nurse obtains a nursing history by interviewing the patient. An interview is a planned communication with four phases: INTERVIEW: Prep In Work Term

the preparatory phase, introduction, working phase, and termination.

Objective 7: Plan patient assessments by identifying assessment priorities and structuring the data to be collected systematically.

the purpose of the assessment offers the best guidance about type/amount of data to collect

Patient-Centered Assessment Method (PCAM):

tool for assessing patient complexity using the social determinants of health that often explain why patients with the same or similar health conditions differ in their ability to manage their health and in their outcomes

Objective 9: Explain when data need to be validated and several ways to accomplish this.

when: to keep data free from error, bias, misinterpretation during or at the end if there is a discrepancy then: analyze, form nursing dx