NRSG 126 - Week 3 Flashcards
nursing assessment
Nursing process
ADPIE (Assessment, diagnosis, planning, implementation, evaluation)
Assessment
o Involves discovery, decision making, critical thinking skills, and data collection.
o supplement, confirm or refute data obtained from history,
o confirm or identify nursing diagnosis,
o make judgements about health status and management,
o evaluate outcomes
Gathering Data from…
o Client health history
o Family health history
o Living situation
o Family friend supports
o ADLs
o Cultural context
Assessment (1st step)
o The first step of assessment is preparation. Find out the client information. Look in:
o Client chart
o Meditech (online chart)
o Kardex
o During documentation (24-hour sheet)
gathering data
o Main Concern: it just depends! If in hospital ED or on
ward, doctors office, PH (which vaccine), HH (specific
needs) etc.
o Health History: what other conditions does the client
have? How could they impact care now?
o Specific Care Needs/ADLs: independent vs
dependent, how do they eat or mobilize?, do they have
any wound. The dependence level changes how we do things, different approach
assessment: data type - subjective and objective
o Subjective: Feelings, Perceptions & Self-report; The client reported 8/10 sharp,
localized pain to their left flank; the client said they are feeling very anxious, denied pain; the client said their dressing feels saturated; shortness of breath is a feeling so subjective,
o Objective: the client has a temperature of 39.4 Celsius; the client was found on the bathroom floor; The client was found on the bathroom floor; client is using accessory muscles; abdomen is distended (bloated)
o Only document what the client said or objective (not opinion)
Assessment types
o Interview
o Emergency/Primary assessment (in an emergency situation)
o Focused assessment (focusing on one issues)
o Head-to-toe assessment
o Depending on the type of assessment the
preparation may be different
data sources
o Primary – patient (best source)
o Secondary – family, physician, allied health (PT/OT), chart
o Tertiary – nurse, experience, literature
primary assessment
o The ABCDE
o The first assessment you will do when you meet
your client
o This is repeated whenever you suspect or
recognize that your client’s status has become, or
is becoming, unstable
Skills of Physical Assessment: Visual check
o Position and expose body
parts so all surfaces can be
viewed.
o Inspect for size, shape, colour, symmetry,
position, drainage, & abnormalities.
o Compare one side with the other side
(right hand & left hand)
o Document any concerns
ABCDE
o Airway: Look for/ consider causes; consider immediate treatment #1
o Breathing: Chest rise, work of breathing, RR, SpO2, auscultation. Look for/ consider causes; consider immediate treatment
o Circulation: Skin colour, temp, pallor, cyanosis, diaphoresis, HR, edema. Look for/ consider causes; consider immediate treatment
o Disability: LOC (go back to check airway, concerning), pain, ability to mobilize, strength. Look for/ consider causes; consider immediate treatment
o Environment/Exposure: Equipment, safety, drains/dressings, client needs. Look for/ consider causes; consider immediate treatment
Skills of Physical Assessment: Auscultation
o Use of stethoscope.
o Familiarity with normal sounds first before
identifying abnormal sounds or variations.
o Characteristics of sounds:
frequency, loudness, quality,
duration.
o Requires concentration &
practice
Skills of Physical Assessment: Percussion
o Client’s body is tapped with fingertips to produce
a vibration.
o Sound indicates location, size, and density of
structures.
o Used primarily by nurse
practitioners & physicians
in practice
Skills of Physical Assessment: Palpation
o Touch.
o Assesses for tenderness, distension, masses.
o The nurse uses different parts of hands to
distinguish texture, temperature, and movement
o Light palpation is generally enough.
o Tender areas are palpated last
medical diagnosis
o Medical diagnosis: The identification of a disease or condition on the basis of specific evaluation of signs and symptoms
Nrsg focus: Implement orders/monitor client
Example: Pneumonia
Assessment Considerations with Older Persons
o Communication techniques.
o Keep them warm.
o Adjust as necessary. (such as pain, pace take more time, give them breaks)
o Utilize knowledge of normal changes of ageing vs
misconceptions. (things take slower but they can still learn things)
o Utilize knowledge of atypical presentations of
illness.
o Utilize knowledge of increased risks associated
with infection and safety
o Document
Nursing diagnosis
potential health problem
Nrsg focus: Treat/prevent
Example: Ineffective airway clearance
Diagnose
o Analyze data collected in the assessment
Identify health problems, risks & strengths
Formulate diagnostic statements and identify
client needs.
o diagnostic label (approved by NANDA),
o related factors (etiology),
o definition of the label (approved by NADA),
o risk factors (may increase vulnerabilities),
o support for the statement (through assessment
findings
plan
o Where goals and outcomes are formulated that directly impact client care
o Involves:
o set priorities,
o establish client-centered goals/outcomes,
o select nursing interventions,
o write a plan of care (PoC)
o consider short- and long-term goals
collaborative problem
o Collaborative problem: An actual or potential complication that nurses monitor to detect a change in client status
Nrsg focus: Prevent and monitor for complications
Example: Potential complication of pneumonia – Sepsis (systemic
infection
plan of care
In the Plan of Care, we need to look at HOW we help the client to meet these goals
plan: acute confusion, pain, and falls risks
o Acute confusion: client to clear from confusion. Make sure the environment is safe
o Acute Pain: client will obtain acceptable levels of comfort. Giving pain medication.
o Risk of Falls: client to safety mobilize independently at home. Use of mobility aids, keep the bed locked rails up, working with PT, matts beside the bed, hip protectors
Implementation
Carrying out or delegating nursing interventions
o promote health,
o prevent complications,
o treat symptoms,
o facilitate coping
Implementation: Situation
o Acute confusion: Ensure PRISME assessed and
appropriate interventions/prevention is maintained
o Acute pain: ensure medications given as ordered
o Risk for falls: Ensure appropriate mobility TID, up for meals
o Follow PT and OT direction.
implementation: acute confusion, pain, and falls risks
o Acute confusion: Ensure PRISME assessed and
appropriate interventions/prevention is maintained
o Acute pain: ensure medications given as ordered
o Risk for falls: Ensure appropriate mobility TID, up for meals
o Follow PT and OT direction.
Evaluation
Process of comparing pt responses to preselected outcomes to determine whether goals have been met
o Have we assisted the client to meet goals, can just be start them and longer ones after
o re-assess,
o evaluate,
o determine if outcomes have been met,
o continue, modify or terminate plan of care
Avoiding Errors
develop critical thinking
o Do I understand the data?
o Did I collect all the relevant data?
o Have I accurately interpreted the information?
o How is my data organized?
o Have I considered other diagnoses?
o Do I need guidance?
Priorities Pyramid: bottom to top
o Physiological needs: breathing, food, water, shelter, clothing, sleep
o Safety and security: health, employment, property, family, and social ability
o Love and belonging: friendship, family, intimacy, sense of connection
o Self-esteem: confidence, achievement, respect of others, the need to be a unique individual
o Self-actualization: morality, creativity, spontaneity, acceptance, experience, purpose, meaning and inner potential
what is documented?
o Assessment findings
o Diagnosis often included in the plan of care
o Implementation of interventions and
o evaluation of such
documentation
o Documents timely and appropriate reports of assessments, decisions about client status, plans, interventions and client outcomes (BCCNM Competency in Standard 2: Knowledge-Based Practice)
o Document findings right after assessments if possible
o AKA Charting
o Communication
o Safe and appropriate care
o Professional and legal standards
documentation examples
o 4 hour flow sheet
o Narrative Nursing Notes
- Charting By Exception
- DAR – Data (assessment data), Action
(nursing intervention), Response
(Evaluation)
o Nursing Care Plans
o Graphic Sheets (vital signs)
o Medication Administration Records (MARs)
what to document?
- Anything heard, seen, felt, or smelled should be
reported accurately:
o Be objective
o Avoid adding in your personal judgement - Subjective client information should be placed in
quotation marks:
o Client reports “sharp” abdominal pain - Accurate terminology and abbreviations must be used.
o Only approved abbreviations should be used
data validation
the comparison of assessment data with another source to check the accuracy
NANDA
an organization that sets a specific set of characteristics for nursing diagnoses
nursing health history
a detailed database that allows nurses to plan and carry out nursing care to meet patient’s needs
Family history
a record of a person’s family relationships and medical history
concept map
a visual representation that shows the connections between a patient’s health problems
physical examination
a check of the body to assess overall health
patient expected outcomes
specific patient behaviours or physiological responses that nurses set to achieve through nursing diagnosis or collaborative problem solution. They provide a clear focus for the interventions necessary to care for the patient.
Patient goals
one goal behaviour or response that reflects the patients highest level of wellness
client centered
heavy emphasis on satisfying the clients need
etiology
cause of disease
kardex
the Kardex card filing system allows for quick reference to the needs of the patient for certain aspects of nursing care
consultation
Involves seeking the expertise of a specialist to identify ways of approaching and managing the planning and implementation of therapies
What role does critical thinking play in assessment and the diagnostic process?
Critical thinking is important in assessment because assessment is the deliberate and systematic collection of data to determine a patients current and past health and functional status to determine the patients present and past coping outcome. Critical thinking helps the nurse have a broader perspective from which to form conclusions and make decisions about a patient’s health condition.
How is subjective and objective data collected?
- Subjective data is explanation the patient provides of their health collected through the health history and the nurse’s questions.
- It is collected using an accepted standard like Celsius, centimeters on a measuring tape, or known characteristics like of anxiety.
When should closed-ended and open-ended questions be used?
- Closed ended questions should be used when the nurse is asking about information that does not need additional information from patient such as: do you feel the medication is help, who is the person who helps you at home, etc.
- Open ended questions should be used when exploring broader issues and wanting the patients explain their history in their own words. They can help find out the patients priorities and primary concerns,
What role does observation play in assessment?
- Observations are important as they can inform the nurse if their observations match what the patient says so they can enhance their objective data base
- Observations direct nurses to gather additional objective data to form accurate conclusions about the patient
What role does diagnostic and laboratory data play in assessment?
- They help reveal or clarify alterations questioned or identified during the nursing health history and physical examination
Why is data validation important?
- It is important to avoid making incorrect inferences and miss important information from the patient
Describe some different types of nursing diagnosis (problem-focused, risk, health promotion, wellness etc.
- There are 4 types of nursing diagnoses: actual, risk, health promotion, and wellness diagnoses.
- Actual diagnosis: describes responses to health conditions or life processes that exist in an individual, family, or community. Defining characteristics that culture in patterns of related cues or inferences support this diagnostic judgment.
- Risk diagnosis: describes human responses to health conditions or life processes that will possibly develop in a vulnerable individual, family, or community
- Health promotion diagnosis: a clinical judgement of a person’s, family’s, or community’s motivation and desire to increase well-being and actualize human health potential, as shown in their readiness to enhance specific health behaviors
- Wellness diagnosis: describes levels of wellness in an individual, family, or community that can be enhanced
What are the 5 sources of diagnostic errors?
- Errors in data collection, errors in interpretation and analysis of data, errors in data clustering, error in the diagnostic statement
How does nursing diagnosis help us with care planning?
- Nursing diagnosis helps us provide direction for the planning process and the selection of nursing interventions to achiever desired outcomes for patients
How can nurses set priorities?
- Nurses can set priorities by determining the most harmful conditions and treating those first. If it is possible the nurse and the patient can select mutually agreed-upon priorities based on the urgency of the problems, safety, the nature of the treatment indicated, and the relationship among diagnoses.
