Chapter 12 assessing Flashcards
What is a nursing assessment and what attributes should assessments have?
What is an assessment used for?
A systematic and continuous collection, validation, analysis and communication of patient data, or information.
An assessment is continuous because patient’s conditions are always changing.\
Information must always be validated to ensure that the data gathered is correct, whether thats physical testing or lab values or whatever.
An assessment paints a picture of the condition of status (mental, physical, or spiritual, cultural etc) in the patient.
It helps identify potential and actual health problems
The primary source of information on the patient.
What are the 4 kinds of assessments? What are the attributes of each?
Initial assessment - performed after admission, purpose is to establish a complete database. Collection is all aspects of health.
The initial assessment gives an idea of priority of care.
Focused assessment - Can be done during the initial assessment. This assessment is generally targeted towards a specific problem that has already be identified, although it can be used to identify new or overlooked problems. This assessment CAN BE CONTINUOUS.
Emergency Assessment - performed when a physiologic or psychological crisis presents itself
LIFE THREATENING problems.
Time lapsed assessment - This creates a point of comparison between baseline and a current. Helps to reassess health status and make revisions to the plan of care. Basically tells if your care plan is working and tells you in what direction you need to adjust goals.
Who can do an assessment?
ONLY A NURSE!
How do we establish assessment priorities?
Gathering only relevant information
Health orientation (risks, indicators etc)
The patients culture (who does the talking, interpreter etc)
Need for nursing (LTC, Acute, birthing etc) Things are going to change based on the specific needs and the assessment should be tailored to that environment
Developmental stage is hugely important
What are some different ways to organize assessment data?
Maslow’s hierarchy - 5 sets of human needs
Gordon’s - functional health patterns (like pattern of eating and drinking
Medical model - body systems
What is the difference between the medical and nursing assessments?
Medical assessments relate to disease or conditions and target data pointing to pathologic conditions
Nursing assessments - assess the response to that health problem ( broken bone causes pain, nurses assess the level of pain and the administer medication via physician order)
What is the difference between objective and subjective data?
Objective data is something that can be measured or seen, heard, or touched by others. Also called Overt data
(temp, skin,moisture,vomiting)
Subjective data is information perceived only by the patient. Also called Covert data
(pain, dizziness,anxious, etc)
What characteristics of data should be be considerate of when doing an assessment and why?
Must be purposeful - must determine the appropriate type of assessment to do and then get the information relevant to that assessment
Information must be complete - try to gather all the information needed to understand a patients problem. If a patient has lost weight then we need to know if it was purposeful or not, or if the patient was exercising.
Factual and Accurate - Both patients and caregivers are subject to bias and misinterpretation. State the facts as they are without interpretation. If the data is incorrect, everything could be off.
Data must be relevant - record concisely all pertinent data.
What are sources of data?
THE PRIMARY SOURCE IS THE PATIENT!
unless stated otherwise it is assumed that all data comes from the patient. HOWEVER, patients with limited capacity or dementia or children cannot be relied on to report data correctly.
Family and significant others - however, a clear understanding of confidentiality must be had. In the records it must state who you got the information from
Patient records - best done in the prep phase before meeting with the patient. Helps to focus the nursing assessment.
Medical,history, physical examination etc - focus on identifying pathogenic conditions and their causes and on determining the medical regimen for treatment
Consultations with specialists - help to find a medical diagnosis or planning/ executing treatment.
Lab reports and diagnostics - can provide objective data that confirm or conflict with data collected during nursing history or examination
Reports of therapies by other healthcare professionals - can get more information how how the patient is doing.
What is the main key form of nursing data collection?
What is the first thing you do?
What other methods of data collection are there?
Observation
Look for signs of distress in the patient ( color, breathing, pain, etc)
Its important to observe subtle changes
Always ask yourself if the patient can take care of themselves
Look at the environment! is everything hooked up? Connected to the patient, working properly? Is the environment safe?
The nursing history
What should you be able to learn from the nursing history?
Should clearly identify the patients strengths and weaknesses, health risks, potential and existing health problems
What are the 4 phases of the nursing interview and what are their characteristics and things that should be done during the phases?
Preparatory Phase - prepare the environment for the interview and make sure its private and relaxed. Check the patients charts and make sure seating arrangements are conducive to interviews.
Introductory Phase - Initial impression of the nurse is critical ( all future engagements might be judged by your first impression). Nurse should assess the patients comfort and ability to participate.
Working phase - where nurse gathers data. must be accurate, complete and validated
Termination phase - possibly do a recap, conclude with an open ended question so that the patient can respond with data the nurse didnt think of. make sure the patient knows what to expect next.
What does the nursing physical assessment focus on as opposed to a medical assessment.
What is its purpose?
What should be especially looking for?
What ROS?
Its concerned with the patients functional abilities.
It gives a appraisal of health status, validates findings in the interview, identifies potential risks, helps complete the database
Something out of the ordinary for that specific patient
Review of systems - systematic head to toe assessment
What are the 4 methods used to collect data in a physical assessment?
inspection, palpation, percussion, and auscultation
If you find a value or and observation that is out of the ordinary for a patient, what do you do?
VALIDATE
