The nursing process Flashcards
Describe elements of the assessment process
> Assess a patient’s acute/chronic needs and holistically assess the biological, social and psychological factors that impact the individual
> Gather both objective and subjective data
- Objective – measurable
- Subjective – from patients as they talk about their perspectives and feelings
> Repeated information (clarification)
> Clinical information (History and Background)
What are the varying names of assessment tools?
> Assessment scales
> Risk assessment tools
> Screening tools
Why are assessment tools useful?
> Check list to ensure all elements of an assessment are completed
> The score generated can give a clear indication of risk
> The score generated can give an indication of either improvement or deterioration
Why shouldn’t assessment tools be used solely when reviewing a patient and what are the factors that should be considered when using these tools?
> They should be used in conjunction with clinical skills and not replace clinical skills
> They do not encourage a holistic approach - incorporate within the use of a model - eg Activities of living – elimination use CRAS tool
> Use tools appropriate to the age of the patient
What are the 3 main types of assessment tools?
> Health screening and diagnosis
> Description
> Prediction
What is the health screening and diagnosis tool used for and what are some examples of what it tests?
To identify the presence and/or the severity of a particular problem
Alcohol use disorders identification test (AUDIT)
> 10 simple questions to detect alcohol problems
Hospital anxiety and depression scale
> 14 questions used to detect anxiety or depression (HADS)
Describe the description tool and what it does and doesn’t do
A purely descriptive tool allows the patient’s condition to be described to someone else
IT DOES NOT
> Don’t diagnose
> Don’t predict
HOWEVER IT DOES
> Give an idea of how bad symptom is and how the patient is feeling
What are some examples of the description tool?
Activities of Living (Als)
> 12 point assessment relating to the activities undertaken by individuals on a daily basis
A visual analogue scale (VAS)
> For pain management, a variety of age related scales are used to identify the extremes and in between levels
Describe the predictive tool and what are some of its examples?
Help decide whether someone is likely to develop a problem in the future
Waterlow’s pressure ulcer risk assessment
> A range of patient characteristics to identify the risk of pressure ulcer development
Constipation risk assessment scale (CRAS)
> Series of questions to predict the likelihood of constipation
Describe a nursing diagnosis
> Nursing diagnoses are based on data obtained during the assessment process
> A nursing diagnosis presents a problem response present at the time of assessment
> A nursing diagnosis identifies problems resulting from that disorder
> Information from the assessment is analysed and problems are identified from which outcomes can be generated.
What is a medical diagnosis
A medical diagnosis identifies a disorder
What are the main differences between a medical and nursing diagnosis
MEDICAL
> Identifies disease
> Remains the same as long as the disease present
Examples include Myocardial Infarction > ECG readings > Blood gases > Medication
NURSING
> Focuses on unhealthy responses to health / illness
> May change from day to day as the patient’s responses change
Examples include > Pain > Breathlessness > Anxiety > Reduced Independence > Knowledge Deficit
What are some types of nursing diagnosis’?
> Problem focused diagnosis
> Risk Nursing Diagnosis
> Health Promotion Diagnosis
