Chapter 1 - Evidenced-Based Assessment Flashcards
1
Q
Evidenced-Based Assessment Using the Nursing Process
A
- The Nursing Process is an interactive and dynamic method for viewing and providing patient care.
- The steps of the process are cyclical, moving in a forward and backward direction.
- Assessment, Evaluation and Re-assessment occur during all steps in the process.
Nursing Process 6 phases:
- Assessment
- Diagnosis
- Planning Outcomes
- Planning Interventions
- Implementation
- Evaluation
2
Q
Assessment
A
Collection of data about the individual’s health state
- Purpose - to make a judgement or diagnosis
- It is systematic
- It includes gathering data that is both subjective and objective
- Data may be gathered from any of the following:
- Review of clinical record
- Health history
- Physical examination
- Functional assessment
- Risk assessment
- Review of the literature
- Data may be gathered from any of the following:
3
Q
Subjective vs. Objective data
A
- Subjected
- Data communicated by the individual, family, or community
- Obtained through interview
- Data is what the client tells you
- use quotation marks
- Ex. Symptoms, values, perceptions, feelings, beliefs, sensations, attitudes
- Objective
- Data gathered via observation (inspection), testing (percussion, palpation, auscultation)
- Physical exam: what you observe through your senses
- Assessment techniques: inspection, percussion, palpation, and auscultation
- Through good communication, open-ended questions, no confrontation, repeating, etc.
- Establish TRUST
4
Q
Primary vs. Secondary data
A
- Primary
- Data gathered via observation (inspection), testing (percussion, palpation, auscultation)
- Secondary
- Data from medical record, test results, other caregivers
5
Q
Diagnostic Reasoning
A
Process of analyzing health data and drawing conclusions to identify diagnosis
6
Q
What is a Nursing Health Assessment?
A
- Foundation of your nursing skills
- First phase of the nursing process
- Focuses on the whole person
- Assessment includes: physical, growth /development, emotional, activities of daily living (ADL’s), patterns of coping, health goals, environment, cultural / religious statuses
- Collects data for nursing and medical purposes.
- Focuses on identifying possible, actual, and/or potential health problems.
- Gathers, validates, & organizes data about the client (individual, family and community).
7
Q
Focus on Assessment
A
This course focuses on assessment, not diagnosis
- Assessment: Collection of data
- Interpretation of data is the beginning of obtaining a Nursing Diagnosis
- Identify clusters of “clues”, make inferences about clusters of “clues” validating the inferences, documentation of nursing diagnosis
- Ex. Clustering data- the patient complains of pain- pain intensity scale, assess for rapid heart rate, increased BP, facial grimacing, body movement and positioning
8
Q
Priority settings
A
As you gather clinical clues during an assessment think about priority settings
- First-level priority problems: emergent, life threatening
- Second-level priority: Next in urgency - require prompt intervention before continued deterioration
- Third-level priority: important to patient’s health but can wait
9
Q
Evidenced-based practice
A
- More than the use of best-practice techniques
- Encompasses the integration of research evidence, clinical expertise, clinical knowledge, and patient values and preferences
10
Q
Collecting Four types of Nursing Assessment
A
Every examiner needs to establish 4 different types of databases
- Complete Health Assessment:
- Full health history and physical exam
- Non-emergent data collected at initial visit, or on hospital admission.
- Episodic/ Problem-centered / Focused
- For limited or short-term problem
- Determination of a specific problem, targeted
- Use OPQRSTU. Pain Assessment
- Interval, or Follow-up:
- Status of an identified problem evaluated
- Follow up on both short- and long-term issues
- Comparison of baseline to now
- Emergency:
- Urgent assessment is collection of crucial information while performing lifesaving measures
- Focuses on ABCs
- More rapid collection of data.
11
Q
OPQRSTU. Pain Assessment
A
- Onset- When did it begin? How long does it last (duration)?, how often does it occur (time)?
- Provoking or palliative factors? What brings it on? What makes it better? What makes it worse?
- Quality- what does it feel like? Can you describe it (throbbing, stabbing, dull)
- Region and Radiation- Does your pain radiate? Where does it spread? Point to where it hurts the most, Where does your pain go from there?
- Severity- What is the intensity? Pain scale (0-10)
- Time & Treatment- When did the symptoms first begin? What medications are you currently taking for this? How effective are the medications?
- Understanding & Impact- What do you believe is causing this? Is it affecting your ADL’s?
Do you have any other concerns?
12
Q
Organize Subjective & Objective Data
A
- Head to Toe Model or Cephalo-caudal:
- Organize the assessment by proceeding with the exam in a “head to toe” order
- Body Systems Model:
- Assessment is organized by body system
- Examples: GI system, GU system
- Abbreviated—may be part or all of a 10-minute health assessment
13
Q
Cultural Considerations
A
- Be careful not to stereotype
- Consider cultural differences in your assessment technique
- Consider your own VALUES in your assessment technique
- Be aware of the perception that your beliefs, values, accepted behaviors are superior to those of other cultures
14
Q
Apply Critical Thinking to
Physical Assessment:
A
Critical thinking goes beyond just knowing the pathophysiology rather than putting together important assessment cues to determine the likely cause of a clinical problem while developing possible interventions.
- Step 1: Identify Abnormal Data from Normal Data
- Step 2: Cluster Collected Subjective & Objective data.
- Step 3: Draw Conclusions to make clinical decisions
- Step 4: Propose possible nursing diagnosis
- Wellness Diagnosis
- Risk Diagnosis:
- Actual Nursing Diagnosis:
- Step 5: Check for defining characteristics
- Must be present in order to use a nursing diagnosis
- Step 6: Confirm or rule in or rule out
“possible” differential diagnoses - Step 7: Document conclusions
15
Q
Possible nursing diagnosis
A
- Wellness Diagnosis
- Based on identified patient strengths; indicates an opportunity for enhancement of health state & client wish to improve health
- “Readiness for enhanced family coping”
- Risk Diagnosis:
- No problem identified, but high risk for developing one. This is a 2 part statement:
“At risk for sleep deprivation related to incisional pain” - Attempting to prevent the occurrence of a problem
- No problem identified, but high risk for developing one. This is a 2 part statement:
- Actual Nursing Diagnosis:
- Actual problem or dysfunctional state. This is a 3 part statement in one sentence:
- Chronic pain…
- R/T (related to) inflammation secondary to arthritis…
- as exhibited by grimacing with motion
- Actual problem or dysfunctional state. This is a 3 part statement in one sentence:
27
Q
Genogram - sample
A
- Circle members of current household.
- Marital separation and divorce give date.
- Miscarriage or abortion use triangle and give year.
- Try to go 2 generations above the patient include parents and grandparents.
Why do you need to know this information? You want to know family history of HBP, heart disease, stroke, diabetes, blood disorders, cancer, sickle cell, obesity, asthma, seizure disorder, mental illness, kidney disease, and tb.
This data may have genetic significance for the patient.
28
Q
Genogram narrative example
A
- Maternal grandmother died, age 86, stroke, maternal grandfather alive and well, age 90
- Paternal grandmother, 72, diabetes with heart attack at age 65.Paternal grandfather, 76, alive & well
- Dad alive and well, age 54.
- Mom, 50, had ovarian cancer 3 years ago
- Twin sisters, 26, alive and well
- 1 brother, 24, with arthritis from sports injury
- Pt. age 30, admitted with appendicitis. Divorced from husband last year. 2 year old boy and 3 y.o. girl at home alive and well.
