Module 6 Flashcards
Assessing
Systematic and continuous collection, analysis, validation, and communication of patient data
Data does what for us on assessment?
reflects how health functioning is enhanced by health promotion or compromised by illness and injury
Database
includes all the pertinent patient information collected by the nurse and other healthcare professionals
ensures the nurse to partner with patients to make a comprehensive and effective care plan
Medical Assessment
targets data pointing to pathologic conditions / exact conditions
Nursing Assessments
focus on the patients response to a health problem and how to prevent those responses
In assessment, the primary source of information is the ____
patient
How is critical thinking linked to assessment?
You have to assess systematically and comprehensively to ID nursing and medical concerns
Detect bias and determine credibility of information sources
Distinguish normal from abnormal findings and ID risks for abnormal findings
Make judgements about data significance
Determine what is relevant and what is not
ID assumptions and inconsistencies, checking accuracy and reliability, and recognizing missing information
Characteristics of a Nursing Assessment
Purposeful Prioritizing Complete (holistic and meaningful to issue) Systematic Factual and Accurate Relevant Recorded in a Standard Manner
4 Types of Nursing Assessments
Comprehensive / Initial
Focused
Emergency
Time-Lapsed
Initial comprehensive assessment
done shortly after admittance
needs to establish a complete database for problem ID and care planning
performed by the nurse to collect data on all aspects of patient health
Focused Assessment
performed during initial assessment or as a routine data collection
performed to gather data on specific problems already ID, or ID new or overlooked problems
Done by the nurse to collect SPECIFIC PROBLEM DATA
Emergency Assessment
When a physical or psychological crisis is present
done to ID life threatening problems
done by nurses to gather data on a LIFE THREATENING PROBLEM
Time Lapsed Assesment
Performed to compare a patients current status to baseline data obtained earlier
Reassesses health status and allows for necessary revisions in a care plan
Done by the nurse to collect data about current health status of the patient
What factors determine assessment priorities?
- Health Orientation (potential and actual risks that influence wellness)
- Developmental Stage (compare what is happening when hospitalized to what occurs outside setting)
- Culture (big role in patient care)
- Need for Nursing (ex: focus on the problem they have, not irrelevant things)
Characteristics of Good Assessment Data Gathered
Purposeful Prioritizing Complete Systematic Factual and Accurate Relevant
Objective Data
observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them
Subjective Data
information perceived only by the affected person
ex: pain, dizziness, anxiety
Potential Sources of Assessment Data
Patient Family and Sig others
Patient records
PMH, Physical exam, progress notes
consultations
reports of lab and other diagnostic studies
reports of therapies by other health are professionals
nursing and other health care literature
Problems related to data collection?
Inappropriate database organization
omission of needed data
inclusion or duplication of misinterpreted, irrelevant, or erroneous data
Failure to establish rapport or partnership with patient
Recording and interpretation of data rather than observed behavior exactly
failure to update database
When should data be verified?
- When there is a discrepancy between what the person says, and what the nurse observes
- When the data seems to lack objectivity
The skill of nursing observation involves determining…
- Patients current responses (emotional and physical)
- patients current ability to manage care
- immediate environment and its safety
- the larger environment (hospital or community)
4 Phases of a Nursing Interview (assessment stage)
- preparatory phase
- Introduction
- Working phase
- termination
How is the Nursing Interview different from the Communication stages?
There is a preparatory stage in the nursing interview
Preparatory Phase
getting printed information to assure you know it, clearing mind of anxiety and bias, visualizing yourself as the optimal caregiver
Introductory Phase
talking comfortably and introducing yourself
Working Phase
active listening, obtaining information, observation work
Termination Phase
asking for a summary of the most important concerns, mentioning to say if they have anything to add later one, being open to more information
Purpose of a Nursing Physical Assessment
- Appraisal of Health Status
- ID health problems
- Establishment of a database for nursing interventions
2 Parts of the Nursing Physical Assessment
- ROS
2. Physical Assessment
Ways to validate inferences
Physical exam with proper equipment and procedure
use clarifying statements
sharing inferences with other team members - communicate
checking findings with research reports
comparing cues to knowledge based of normal function
checking consistency of cues
How does the phases of assessment set the stage for diagnosis?
Collecting data, ID cues and inferences, Validating data, clustering related data into patterns, and reporting & recording make up ASSESSMENT –> which leads to CLINICAL REASONING (analyze, synthesize, reflect, make judgment, draw conclusion) –> which leads to the DIAGNOSIS
How should documentation of data occur?
SAME DAY
Do immediately when critical changes occur in health status
Enter initial database into record the same day as admission while summarizing objective and subjective data concisely, comprehensively, and in a way that can be retrieved easily
Use good grammar and standard abbreviations
When possible, use patients own words
avoid non specific terms subject to individual definition/interpretation
When assessing and documenting data is is important for the nurse to…
have their primary ethical responsibilities in mind for privacy, confidentiality, and professionalism
Be familiar with HIPAA and institutional policies
Nursing Diagnosis
a clinical judgment / describe patient problems a nurse can treat independently
NANDA I
group making nursing diagnosis guidelines
Purpose of the Diagnosis step of the nursing process
ID how someone, group, or community responded to actual or potential health and life processes
ID factors that contribute to, or cause, health problems (etiologies)
ID resources or strengths on which the individual, group, or community can draw to prevent or resolve problems
Nursing concerns and responsibilities related to diagnosis
Recognizing safety and infection risks and addressing them ASAP
ID human responses to things and how treatment impacts a patients life while promoting optimal health
Anticipating possible complications and trying to prevent them
Initiating urgent interventions if needed
What is “Predict, Prevent, Manage, Promote”
We must PREDICT the most common and most dangerous complications
Make immediate actions to PREVENT
MANAGE them if they cannot be prevented
Promote optimum function, independence, and sense of well being by ensuring safety and learning needs are met
3 Types of Diagnoses
Nursing
Medical
Collaborative Problem
Medical Diagnosis
describe problems for which the physician directs the primary treatment
Collaborative Problems
managed by using physician-prescribed and nursing-prescribed interventions
ex: Medical Diagnose Cancer –> Radiotherapy as surgical treatment –> diagnostic study in exploratory test
Diagnostic and Clinical Reasoning tips
Be familiar with nursing diagnosis and health problems through literature
trust clinical expertise and judgement, but be willing get help when needed
respect intuition but dont have 0 evidence
recognize your bias & keep an open mind
Skills Needed To Work In Partnership
respect and care when speaking
effective listening
respect the opinions and views of others
know how to validate perceptions w patients and families
4 Steps of Data Interpretation and Analysis
Recognizing Significant Data (compare to standards) –> Recognize patterns or clusters –> ID strengths and problems and potential complications –> Reach a conclusions
Possible Results when reaching conclusions?
No Problem
Possible Problem
Acute or Potential nursing Diagnosis
Clinical problem other than nursing diagnosis
3 components of the Nursing Diagnosis
Problem - Etiology (r/t) - Defining Characteristics (AEB)
What is unhealthy r/t Factors maintaining unhealthy state AEB subjective and objective data signaling existence of problem
Types of nursing diagnoses
Problem focused
risk
health promotion
(with defining characteristics and related factors stated too)
Problem focused nursing diagnosis
patient has a problem
ex: impaired bed mobility r/t left side paralysis
ex: sleep deprivation r/t pain
Risk nursing diagnosis
Diagnosis of a risk for something due to something
ex: Risk for skin integrity r/t incontinence
ex: RIsk for ineffective breathing pattern r/t dyspnea
Health promotion nursing diagnosis
Readiness for ____
ex: Readiness for enhanced nutrition
Ways to validate the nursing diagnosis?
Is my database sufficient, accurate, and supported by research? (do I have everything)
Does data synthesis demonstrate a pattern?
Are the subjective and objective data characteristics of the problem defined?
Is my nursing diagnosis based on EBP and clinical expertise?
It the diagnosis able to be prevented, reduced, or resolved by independent nursing action?
Is my degree of confidence above 50% that other qualified practitioners would formulate the same diagnosis?
Keep in mind what while documenting on EHR
view ongoing risks and problems others have ID’ed
Decide on the doc, new N diagnosis based on assessment findings
facilitate communication of ACTUAL problems with other healthcare providers
Use N diagnosis to make decisions on what mutual goals of the patient are
determine and document when N diagnosis are resolved
Benefits of the nursing diagnosis
Individualized patient care
Defining domain of nursing to health care administrators, legislators, and providers
Seeking funding for nursing and reimbursement for nursing services
Limitations of the nursing diagnosis
If used incorrectly, misdiagnosis occurs
Nursing practice may be restricted
Common errors when writing a nursing diagnosis?
Writing in terms of needs and response
Making legally inadvisable statements
ID a problem response that isnt necessarily unhealthy or that cannot be changed by us
ID environmental factors rather than patient ones
Reversing clause order
having both clauses say the same thing
including value judgements
Including medical diagnosis in the diagnostic statement
When writing a nursing diagnosis be…
simple, do not overcomplicate
Sources of Error for the Nursing Diagnosis
premature diagnosis from incomplete databases
erroneous diagnosis from inaccurate database or analysis
Routine diagnosis from failure to tailor data collection and analysis to that patients unique needs
Omission errors
