Lecture Week 3: Health Assessment Flashcards
What is the nursing process?
ADPIE:
Assessment: what data is collected?
Diagnosis: what is the problem?
Planning: how to manage the problem?
Implementation: putting the plan into action
Evaluation : did the plan work?
What occurs during the assessment phase of the nursing process?
Involves discovery, decision making, critical thinking skills, and data collection
- Supplement, confirm, or refute data obtained from history
- Conform or identify nursing diagnosis
- Make judgements about health status and management
- Evaluate outcomes
First step is assessment; how do we prepare?
Client chart
MEDITECH (online chart)
Kardex
Nursing documentation (24-hour sheet)
Gathering data:
Client health history
Cultural and context
Family health history
Living situation
Family, friends, supports
ADLs
What data must be gathered for the assessment phase of the nursing process?
Client health history
Cultural and context
Family health history
Living situation
Family, friends, supports
ADLs
Main concern: depends; if in hospital ED or on ward, doctors office, PH (which vaccine), HH (specific needs), etc
Health history: what other conditions does the client have? How could they impact care now?
Specific needs / ADLs: independent vs dependent, how do they eat or mobilize? Do they have any wounds?
What are the types of assessment that are performed?
Interview
Emergency / primary assessment
Focused assessment (main concern of patient; MSKL, N, CVS, pain)
Head-to-toe assessment
Subjective vs objective assessment?
documentation prioritizes objective>subjective; measurable
S: Feelings, perceptions, & self report
OR
O: Observations, measurements, & verifiable facts
Subjective: a
The client reported 8/10 sharp, localized pain to their left flank
The client said they are feeling very anxious about surgery
The client was grimacing but denied any pain
The client said their dressing feels saturated
The client reports SOB
Objective: b
The client has a temperature of 39.4 Celsius
The client was grimacing but denied any pain
The client was found on the bathroom floor
The client is using accessory muscles (SOB)
Abdomen is distended
Primary vs Secondary vs Tertiary data sources?
Primary
- client
Secondary
- family
- physician
- allied health (PT/OT)
- chart
Tertiary
- experience
- literature
- nurse
What are the ABCDEs?
The ABCDEs (PRIMARY)
The first assessment that is done when you meet your client
Repeated whenever you suspect or recognize that your client’s status has become or is becoming, unstable
Airway: #1
Look for/consider causes; consider immediate treatment
Breathing: chest rise, work of breathing, RR, SpO2, auscultation
Look for/consider causes; consider immediate treatment
Circulation: skin colour, temperature, pallor, cyanosis, diaphoresis, HR, edema,
Look for/consider causes; consider immediate treatment
Disability: LOC, pain, ability to mobilize, strength
Look for/consider causes; consider immediate treatment
Environment/Exposure: equipment, safely, drain/dressings, client needs
Look for/consider causes; consider immediate treatment
Safety assessments?
Point of care risk assessment
Infection control practices
Falls prevention
UBCO: scope of practice
BCCNM: BCCNM RN
What are the skills of physical assessment?
Inspection, auscultation, palpation, percussion
Skills of physical assessment: Inspection
Visual check
Position and expose body parts so all surfaces can be viewed
Inspect for size, shape, colour, symmetry, position, drainage, and abnormalities
Compare one side with the other side (left and right hand)
Document abnormalities and what you did in response🙂↕️🙂↕️
Skills of physical assessment: Auscultation
Use of stethoscope
Familiarity with normal sounds first before identifying abnormal sounds or variations
Characteristics of sounds: frequency, loudness, quality, duration
Requires concentration and practice
Document data and action
Skills of physical assessment: Palpation
Touch
Assess for tenderness, distension, masses
The nurse uses different parts of hands to distinguish texture, temperature, and movement
Light palpation is generally enough
Tender areas are palpated last
Skills of physical assessment: Percussion
Client’s body is tapped with fingertips to produce a vibration
Sound indicates location, size, and density of structures
Used primarily by nurse practitioners and physicians in practice
Considerations with older persons when performing assessments
Assessment: may take longer, may need rest periods, signs and symptoms may differ
- Communication techniques
- Keep them warm
- Adjust as necessary
- Utilize knowledge of normal changes of aging vs misconceptions
- Utilize knowledge of atypical presentations of illness
- Utilize knowledge of increased risks associated with infection and safety
What occurs during the diagnosis phasis
Diagnose: analyze data collected in the assessment
- Identify health problems, risks, and strengths
- Formulate diagnostic statements and identify client needs
What should be considered during the diagnosis phase of the nursing processs?
Consider the:
Diagnostic label (approved by NANDA)
Related factors (etiology)
Definition of the label (approved by NADA)
Risk factors (may increase vulnerabilities)
Support for the statement (through assessment findings)
What is the difference between nursing, medical diagnosis and collaborative problem and all of their nursing focuses?
Nursing diagnosis: a clinical judgement about client responses to an actual or potential health problem
nrsg focus: treat/prevent
ex. ineffective airway clearance
Medical diagnosis: the identification of a disease or condition on the basis of a specific evaluation of signs and symptoms
nrsg focus: implement orders/monitor client
ex. pneumonia
Collaborative problem: an actual or potential complication that nurses monitor to detect a change in client status
nrsg focus: prevent and monitor for complications
ex. potential complication of pneumonia - sepsis (systemic infection)`
What is NANDA?
A nursing diagnosis is defined by NANDA International (2013) as a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response, by an individual, family, group, or community.
ex.
Acute confusion
Acute pain
Risk for falls
What occurs during the planning stage of the nursing process?
Where goals and outcomes are formulated that directly impact client care
Planning involves:
Set priorities
Establish client-centered goals / outcomes
Select nursing interventions
Write a plan of care(PoC)
Consider short and long-term goals
What occurs during the implementation stage of the nursing process?
: carrying out or delegating nursing interventions
Includes all activities performed to:
Promote health
Prevent complications
Treat symptoms
Facilitate coping
What occurs during the evaluation process of the nursing process?
Evaluation: process of comparing pt responses to preselected outcomes to determine whether goals have been met
Includes lal activities performed to:
Reassess
Evaluate
Determine if outcomes have been met
Continue, modify, or terminate plan of care
Have we assisted client to meet their goals
Is the client:
Clear from confusion
Comfortable
Had any falls
After implementation and evaluation; repeat
How do you avoid errors in the nursing process?
Avoiding errors:
Do I understand the data?
Did I collect all the relevant data?
Have I accurately interpreted the information?
How is my data organized?
Have I considered other diagnoses?
Do I need guidance?
Priorities in nursing: critical thinking
Nursing diagnosis A:
High urgency and importance:
Client daughter yells that her mother cannot breath and they need a nurse’s help now
Client needs assistance to get to the toilet
Nursing diagnosis B:
Low(er) urgency and importance:
Client fell on the floor, is conscious and
Client is very hungry for lunch and needs help to sit up at bedside
Key Takeaways for NCLEX & Nursing Priorities:
Always prioritize life-threatening conditions first (ABCs).
Think about the risk of rapid deterioration—who could get worse fast?
Stable but uncomfortable patients (pain, hunger) come after unstable ones.
Tasks that can wait (mobility, routine meds) are lowest priority.
Assessed based on Maslow’s hierarchy of needs:
1. psychological needs
2. safety and security
3. love and belonging
4. self-esteem
5. self-actualization
What are the aspects of Cultural considerations and TIP:
6 principles of TIP
4Rs
Respect
Utilize therapeutic communication
Do not impose personal values or beliefs
