215- Ch. 1 Analyzing Data to Make Accurate Clinical Judgments

What is assessment?

Collecting subjective and objective data

Holistic nursing assessment

Collects holistic subjective and objective data to determine a client's overall functioning in order to make a professional clinical judgment

A client presents to the health care facility with reports of new onset of chest pain of 3 days duration. Vital signs are stable and the chest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse to perform for this client?

Comprehensive -This client presents with a new problem, for which the nurse should perform a comprehensive assessment. Chest pain is an emergent problem, but the client has stable vital signs and no chest pain; an emergency assessment thus is not indicated at this time. A partial or focused assessment would not allow collection of enough data to properly diagnose the cause of a new problem.

What is planning?

Determining outcome criteria and developing a plan

When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what?

Diagnosis -Diagnosis occurs when the data has been analyzed and a professional judgment occurs. Assessment is the collection of data. Planning is determining outcome criteria and developing a plan. Evaluation assesses whether the outcome criteria have been met.

Revising the plan as needed occurs in what part of the nursing process?

Evaluation -Evaluation assesses whether the outcome criteria have been met and revising the plan as necessary.

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?

Evaluation -The evaluation stage of the nursing process involves assessing whether the outcome criteria have been met and the nursing care plan needs to be revised. The assessment stage involves collecting subjective and objective data. The diagnosis phase involves analyzing subjective and objective data to make a professional nursing judgment. The implementation phase involves carrying out the plan to meet the determined outcome criteria.

A group of nurses are reviewing information about the potential opportunities for nurses who have advanced assessment skills. When discussing phenomena that have contributed to these increased opportunities, what should the nurses identify?

Expansion of health care networks -Opportunities for nurses with advanced assessment skills will be enhanced by the expansion of health service networks, increasing complexity of acute care, growing aging population with complex morbidities, expanding health care needs of single parents, increasing impact of children and homeless on communities, intensifying mental health issues, and increasing reimbursement for health care promotion and preventive services. Public mistrust of physicians is not a noted phenomenon.

Physical medical assessment

Focuses primarily on the client's physiologic development status

For which client should a nurse perform a focused assessment?

Four-day history of sore throat and fever with enlarged lymph nodes -A client with a sore throat and fever with enlarged lymph nodes requires only a focused assessment by the nurse. A focused assessment consists of a thorough assessment of a particular client problem. An elevated blood pressure with no previous history of heart problems requires an initial or comprehensive assessment. Right upper abdominal pain that radiates into the groin area is an emergency situation and the nurse should collect only the data necessary to make a quick diagnosis for immediate treatment. A client with diabetes has a chronic, ongoing health problem that needs reassessment and possibly a change in treatment.

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about?

Head-to-toe -A head-to-toe or comprehensive assessment is the most organized system for gathering comprehensive physical data.

A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment?

"I'm going to assess the client now so that I can begin formulating the care plan." -Each person needs a complete health assessment. Ideally this is done on admission, but extenuating circumstances may prohibit its completion in detail at this time. The sooner the health assessment is completed fully, the better the nurse knows the client, and more holistic care can be provided to ensure health promotion and quality of life.

A nurse is assessing the cognitive function of a 13-year-old boy who is in the hospital following a head injury sustained while playing football. The boy acts annoyed with the assessment questions and asks how often he will have to answer them. The nurse should respond with which of the following?

"I'm sorry, but assessment is ongoing and continuous." -Although the assessment phase of the nursing process precedes the other phases in the formal nursing process, be aware that assessment is ongoing and continuous throughout all the phases of the nursing process.

When the nurse is performing a physical examination on admission of a client to the medical unit, the client says the doctor already did an exam. The best response by the nurse would be

"the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease." -The medical examination focus is on diagnosis and treatment of disease and the nursing examination focuses on the human response.

What are two methods of organizing data?

-functional assessment strategy -review of body systems

Hypothesis errors include

-identifying a problem that is not treatable by a nurse (ex: problem related to equipment/test-result) -be sure to establish one problem in a statement

Nursing action

-nursing initiated: independent, requires no supervision ex: assessing client's level of anxiety -physician initiated: nurses carry out a written order (ex: medicate with pain drugs per order) -collaborative: ex: dietician, OT, consult with social worker

What are some methods of assessments?

-observation (senses) -interviewing, screening=broad, focused=targeted -physical exam techniques (inspection,palpitation,percussion,auscultation) -intuition (gut feeling)

Give examples of secondary sources in subjective data

-peds patient, mentally handicapped, health records, other HC providers

When planning/generating solution one should

-set appropriate goals (realistic, client centered, single factor) -measurable

How do you accurately identify client needs/problems?

-start with considering client concern/problem/issue -collect valid & pertinent data -differentiate nursing from collaborative data -focus on PRIORITY

Reflection should involve

-the effectiveness of actions -comparing client's response to goal to determine if goal is achieved (ex: client states pain is controlled) -conclude if you need to revise plan, discontinue plan, continue plan

Examples of objective data includes

-vital signs -lab results -diagnostic test results -physical assessment *see & measure

When assessing data what should you look at?

-what is normal/expected, what is abnormal/unexpected, what risk factors are present

What are the five steps of the nursing process?

1. Assessment 2. Diagnosis 3. Planning 4. Interventions 5. Evaluation

Support of diagnostic equipment problem includes what (PES)

1. Problem/concern/issue 2. Etiology (contributing factors or causes) 3. Signs and symptoms

Creating a hypothesis based upon your data/cues is what step in the process?

2nd step *RN validates, analyzes, integrates assessment information to identify clients' needs & problems

A student nurse is learning to document an initial assessment. What would the instructor tell the student that accurate documentation of this specific assessment best provides?

A baseline for comparison with future findings -Accurate documentation provides a baseline so that changes are noted between assessments.

When assisting a client with health promotion, what must the nurse also nurture?

A healthy environment -In order to assist a client with health promotion, a healthy environment must also be nurtured.

What is diagnosis?

Analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, referral)

What are nurses able to detect through the health assessment?

Areas in need of health adjustments -Through the health assessment nurses are able to detect areas in need of health adjustments.

A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption?

Ask the client about the most recent experiences of pain. -Data are best validated by the client. Other sources are valid and useful, but the client is the ultimate source, especially in the case of subjective data.

How does a nurse best facilitate the nursing health assessment?

Asking the appropriate questions -Knowing how to facilitate the nursing health assessment by asking appropriate questions to obtain more information assists the nurse to solve the mystery or create a nursing care plan.

What is evaluation?

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

What is the first step of the nursing process?

Assessment -collects/validate/organize/communicate the client data -includes physical, psychological, emotional, socio-cultural, spiritual

Which assessment finding should the nurse document as objective data?

Body functions -Objective data is what the nurse assesses or observes when performing care of a client

A clinical instructor is teaching a nursing student group about organizing data when documenting and communicating assessment findings. The clinical instructor knows that the method being taught promotes critical thinking and clustering of similar data. The instructor is teaching about which type of assessment?

Body systems -A body systems approach is a logical tool for organizing data when documenting and communicating findings. This method promotes critical thinking and allows nurses to analyze findings as they cluster similar data

What is implementation?

Carrying out the plan

Give examples of primary sources in subjective data

Client statements, complaints *use quotation marks

What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain?

Collecting data regarding the nature of the pain -The nurse's initial role in health assessment is to collect data. Teaching would occur later in the process. Planning care and identifying interventions are parts of the nursing process and not the health assessment.

A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data?

Inspection -Interviewing, therapeutic communication, caring, empathy, and listening skills are needed to obtain subjective data. Inspection, palpation, percussion, and auscultation are used to collect objective data.

A nurse is distracted during her assessment of a client and does not take as thorough or as accurate notes as usual. Her supervisor, who is familiar with the client, reads the client's chart and questions the nurse. The supervisor should point out to the nurse that which of the following errors is most likely to occur due to the nurse's lapse?

Making incorrect nursing judgments or diagnoses -Assessment is the first and most critical phase of the nursing process. If data collection is inadequate or inaccurate, incorrect nursing judgments may be made that adversely affect the remaining phases of the nursing process. Interjection of the nurse's thoughts or feelings may lead to bias or the withholding of information but would not necessarily result from a lack of a thorough and accurate assessment of a client. Nursing judgments should rely on both objective and subjective information; thus this is not an error. Validating information that is correct makes more work for the nurse but will not be prevented by a thorough and accurate assessment of a client.

Which of the following is the best example of holistic data collection by a nurse?

Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings -The purpose of a nursing health assessment is to collect holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment. The nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the client. Thus the nurse performs holistic data collection. The mind, body, and spirit are considered to be interdependent factors that affect a person's level of health. The nurse, in particular, focuses on how the client's health status affects his activities of daily living and how the client's activities of daily living affect his health. For example, a client with asthma may have to avoid extreme temperatures and may not be able to enjoy recreational camping. If this client walks to work in a smoggy environment, it may adversely affect his asthma. The other answers pertain only to the physiologic functioning of the client and not the other aspects.

Which of the following is the best example of assessment in everyday life?

Measuring the remaining tread on a car tire to determine whether it is time to replace it -As a professional nurse, you will constantly observe situations and collect information to make nursing judgments. This occurs no matter what the setting: hospital, clinic, home, community, or long-term care. You conduct many informal assessments every day. For example, when you get up in the morning, you check the weather and determine what would be the most appropriate clothing to wear. Measuring the remaining tread on a car tire to determine whether it is time to replace it is an example of assessment, as it involves gathering information (the height of the tire tread) to make a decision (whether to buy new tires). The other answers do not involve gathering information to make a decision.

How does a nurse decide what health-promotion activities are necessary for a particular client?

Nurses collaborate with clients to identify areas in which clients are willing to make changes -Rather than addressing all areas associated with healthy behaviors and overwhelming clients, nurses collaborate with them to identify areas in which clients are willing to make changes. When caring for a client, a nurse does not address healthy behaviors only; nurses do not address only areas where clients are willing to make changes, nor do they construct their own theories to identify perceptions, barriers, and positive outcomes.

An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of?

Nursing intervention -Nursing interventions are used to monitor health status; prevent, resolve, or control a problem; assist with ADLs; or promote optimum health and independence.

The client has a murmur. This is what type of data?

Objective -Objective data includes data that is measurable. Subjective data is what the client states, feels or senses. Focused and comprehensive are types of assessments

The nurse is exhibiting critical thinking in which client care situation?

Performing a focused assessment on a client who is complaining of shortness of breath. -The nurse investigating a client problem by performing a focused assessment is exhibiting critical thinking. Transcribing orders, calling a healthcare provider, and answering a call bell are not examples of critical thinking that entail outcome-directed thinking based on the nursing process.

The nurse is following a structured head-to-toe approach to identify changes in a client's body systems. Which component of the health assessment is the nurse completing with the client?

Physical examination -In the physical examination, the nurse uses a structured head-to-toe approach to identify changes in the client's body systems. The health history is when the nurse asks pertinent questions to gather data from the client and/or family. Goal setting and planning care are not parts of the health assessment.

The nurse prepared to complete a comprehensive health assessment on a client in the community. What should the nurse expect to complete when performing this assessment? Select all that apply.

Physical examination and Health history -A comprehensive health assessing includes a health history and physical examination. Wellness teaching cannot be done until the client's needs are identified. Outcome identification is a part of planning. Medication administration is a part of implementation.

The client has a headache. What type of data is this?

Subjective -Subjective data is what the client states, feels or senses. The nurse cannot observe a headache. Objective data includes data that is measurable. Focused and comprehensive are types of assessments.

A nurse is working with a client who has AIDS. Which of the following is an example of subjective data that might be gathered for this client?

The client's pain level -Subjective data are sensations or symptoms (e.g., pain, hunger), feelings (e.g., happiness, sadness), perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. Objective data are those that the nurse observes directly, and include the following: physical characteristics (e.g., skin color, posture); body functions (e.g., heart rate, respiratory rate); appearance (e.g., dress and hygiene); behavior (e.g., mood, affect); measurements (e.g., blood pressure, temperature, height, weight); and results of laboratory testing (e.g., platelet count, x-ray findings).

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment?

To determine any changes from the baseline data -Ongoing or partial assessments help to determine any major changes from the baseline data. The nurse collects subjective data related to the client's overall health and conducts a comprehensive health assessment during the initial comprehensive assessment to determine baseline data. The nurse makes a rapid assessment for prompt treatment in life-threatening situations when an immediate diagnosis is needed to provide prompt treatment (emergency assessment). Evaluation is done after an intervention to determine whether the outcomes have been achieved.

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment?

To establish a database against which subsequent assessments can be measured -A health assessment is performed to gain further insight into the current condition and to establish a database that subsequent assessments can be measured against.

A client is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the client?

airway -The emergency assessment involves a life-threatening or unstable situation, such as a client in an ED who has experienced a traumatic injury. Staff members at the ED use triage to determine the level of urgency by considering assessments based on the mnemonic A, B, C, D, E: A-Airway; B-Breathing; C-Circulation; D-Disability; and E-Exposure.

A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment?

empathy -Empathy is an intuitive awareness of what the client is going through; it helps the nurse to be effective in providing for the client's needs while remaining compassionately detached. Inspection and palpation are skills that help the nurse in collecting objective data of the client's physical characteristics. Sympathy is a feeling that would make the nurse as emotionally distraught as the client; this hampers the ability of the nurse to provide client care.

During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. Which category of health is affecting this client?

environmental -The environment influences conditions to promote health. Physical health is the way the body works and adapts. Social well-being identifies relationships that support health. Developmental level focuses on thinking, problem solving, and decision making.

An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n)

focused or problem-oriented assessment. -A focused or problem-oriented assessment does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A focused assessment consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem.

The result of a nursing assessment is the

formulation of nursing diagnoses. -Analysis of data (often called nursing diagnosis) is the second phase of the nursing process. Analysis of the collected data goes hand in hand with the rationale for performing a nursing assessment. The purpose of assessment is to arrive at conclusions about the client's health. To arrive at conclusions, the nurse must analyze the assessment data.