Week 3: health assessment vs. documentation Flashcards
understand the nursing process and the steps involved
what role does critical thinking play in assessment and teh diagnostic process
how is subjective data collected?
how is objective data collected?
describe the different sources of data
what is the purpose of a client interview?
when should closed-ended and open-ended questions be used?
what cultural considerations are required in assessment?
in what ways can nurses support indigenous peoples?
what role does observation play in assessment?
what role does diagnostic and laboratory data play in assessment?
why is data validation important?
why is analysis and interpretation important?
describe some different types of nursing diagnosis help us with care planning?
what are the 5 sources of diagnostic errors?
how does nursing diagnosis help us with care planning?
how can nurses set priorities
what is a collaborative problem?
What is ADPIE
the nursing process involves the steps of:
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 is assessment:
Assessment invovles discovery, decision making, critical thinking skills and data collection
what are the main purpose of assessment?
- supplement, confirm or refute data obtained from history
- confirm or identify nursing diagnosis
- make judgements about health status and management
- evaluate outcomes
what are we looking for in the preparation of assessment?
Gathering data: about client
- client health history
- family health history
- living situation
- family/ friend supports
- ADLs
- cultural & context
The 3 main focuses on gethering data in assessment
- main concern: it just 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 care needs/ ALDs: independent vs. dependent, how do they eat or mobilize?, do they have any wounds?
4 types of assessment
interview
emergency/ primary assessment
focused assessment
head-to-toe assessment
(depending on the type of assessment the preparation may be different)
what is 2 data types?
subjective vs. objective
feelings, perceptions & self-report vs. observations, measurements & verifiable facts
what is subjective data?
: Feelings, perceptions & self-report (anything the clients was, feel, said)
e.g.
* 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
what is objective data?
: observation, measurements & verifiable facts
e.g.
* 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
* abdomen is distended
what are the examples of primary/ secondary/ teritary data sources?
primary: directely collected= client
secondary: family, physician, allied health PT/OT, Chart
teritary: nurse experiences, literature
what is primary data in assessment
- the ABCDE
- the first assessment you will do when you meet your client
- this is repeated whenever you suspect or recognize that your client’s status has become or is becoming, unstable
What does the ABCDE stand for?
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, temp, pallor, cyanosis, diaphoresis, HR, edema
* look for/ consider causes; consider immediate treatment
disability: LOC, pain, ability to mobilize,s trength
* look for/ consider causes; consider immediate treatment
Environment/ exposure: equipment, safety, drains/ dressings, client needs
* look for/ consider causes; consider immediate treatment
- the first assessment you will do when you meet your client
- this is repeand whenever you suspect or recognize that your client’s stunts have been, or is becoming unstable
what should be considered for safety in assessment
- point of care risk assessment
- infection control practices
- falls prevention
- UBCO scope of practice
- BCCNM: BCCNM RN
What are the skills of physical assessment for inspection
- visual check
- position and expose body parts so all surfaces can be viewed
- inspect for size, shape, colour, symmetry, position, drainage, & abnormalities
- compare on eside with the other side (right hand & left hand)
e.g. cyanosis, abdominal sitension, pallor
What are the skills of physical assessment for auscultation
- use of stethoscope
- familiarity with normal sounds first before identifying abnormal sounds or variations.
- characteristics of sounds: frequency, loudness, quality, duration
- requires concentration & practice
What are the skills of physical assessment for palpation
- touch
- assesses 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
What are the skills of physical assessment for percussion
- Client’s body is tapped withfingertips to produce a vibration.
- Sound indicates location, size,and density of structures.
- Used primarily by nurse practitioners & physicians inpractice.
what are the considerations with older persons
- Communication techniques.
- Keep them warm.
- Adjust as necessary.
- Utilize knowledge of normal changes of ageing vs misconceptions.
- Utilize knowledge of atypical presentations of illness.
- Utilize knowledge of increased risks associated with infection and safety.
- may take longer
- may need rest periods
- signs and symptoms may differ
what is dianose in ADPIE
: analyze data collected in the assessment
* identify helath problems, risks & strengths
* formulate diagnostic statements
* identify client needs
what should nurses consider in the diagnose stage
- 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 are the strategies for communicating effectively with older persons
- Try to find a quiet room with minimal outside noises for communication
- Sit facing the patient so that they can watch your lip movement its and facial expressions
- If masks must be worn for safety, consider how to maintain an interaction that is warm, open and demonstrates interest in what the older person is saying
- If needed, make sure that glasses and hearing aids are being worn
- Speak slowly and clearly (do not speak loudly)
- Keep your tone of voice low; older persons can hear low-frequency sounds better than high-frequency sounds
- Periodically summarize what has been said to clarify that you have understood what the older person was saying, and repeat key points
- Ask the older person to explain what they understood and invite questions clarify information. There may also be cultural aspects related to communication
- Emphasize and integrate emotional and personal values in the acquisition of skills and ideas
what are the 3 types od diagnosis
- nursing diagnosis
- medical diagnosis
- collaborative problems
what is nursing diagnosis
: A clinical judgement about client responses to an actual or potential health problem
Nrsg focus: Treat/prevent
Example: Ineffective airway clearance
what is 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
what is 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)
examples of atypical presentation of illness in older populations
- Delirium (acute confusion) with an acute illness is considered a medical emergency
- Depression without sadness
- Infectious disease without fever or tachycardia
- Myocardial infarction without chest pain
- Nondyspneic pulmonary edema
- Abdominal pain is absent or vague
- Confusion is not inevitable. Look for neurological events, new medication, or the presence of risk factors for delirium
- Many hospitalized older persons suffer from chronic dehydration accelerated by acute illness
Not all older persons have fevers with infection; most common are respiratory or urinary tract infections. Symptoms may include increased respiratory rate, falls, incontinence, or confusion.
NANDA
nursing diagnoses
what is plan in ADPIE
where goals and outcomes are formulated that directly impact client’s care
what are involved in planning:
Set priorities
establish client-centered goals. outcomes,
select nursing interventions
write a plan of care (PoC0
= consider short & long-term goals
how the goals & outcomes made out from planning (the process)
circular:
diagnosis -> medical & nursing goes to
cleint expectations & health care expaecations or vice versa
= goals & outcomes
In the plan of Care, we need to look at HOW we help the client to meet these goals: what are those goals?
- Client to clear from confusion (long term goal)
○ complete CAM & PRISME. Treat P.R.N - Client will obtain acceptable levels of comfort (short term goal)
○ Scheduled analgesic. Offer before mobility - Risk of falls
○ Have PT/ OT assess. Up for meals. Mobilize TID.
what is Implementation in ADPIE
carrying out or delegating nursing interventions
what implementation includes all activities performed to:
- promote health
- prevent complications
- treat symptoms
- facilitate coping
implementation for acute confusion
main goal: client to clear from confusion
- ensure PRISME assessed and appropriate interventions/ prevention is maintained
implementation for acute pain
main goal: client will obtain acceptable levels of comfort
* ensure medications given as ordered
implementation for risk for falls
main goal: client to safely mobilize independently at home
* ensure appropriate mobility TID, up for meals. follow PT and OT direction
what is evaluation phase in ADPIE
process of comparing pt responses to preselected outcomes to determine whether goals have been met
what are the expected activities in evaluation
- re-assess
- evaluate
- determine if outcomes have been met
- continue, modify or terminate plan of care
after implementation, check if the client is:
(3)
clear from confusion
comfortable
had any falls
what are the questions to avoid 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?
= develop critical thinking
what is critical thinking in nursing?
“Nursing is a dynamic, continually evolving discipline that employs critical thinking to integrate increasingly complex knowledge, skills, technologies, and client care activities into evidence-based nursing practice. The goal of nursing for client care is preventing illness and potential complications; protecting, promoting, restoring, and facilitating comfort, health and dignity in dying.” (NCSBN, 2018).
critical thinking involved priorities in nursing
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
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
Cultural Considerations and TIP
“do not impose personal values or beliefs”
- 6 principles of TIP
- 4Rs
- respect
- utilize therapeutic communication
- cultures:
○ Age
○ Ethnicity
○ Status
○ Religion
○ Gender
○ Way of life
Awareness of potential abuse
Client abuse
- Neglect
- Physical injury
- Is there fear?
- History
Substances abuse
- Missed appts
- Excuses
- GI bleeds or ulcers
- CAGE
Documentation:
◊ Client reported pain
◊ Client reported pain to the right shoulder
◊ Client reported 8/10 sharp pain to the right shoulder
◊ Client reported 8/10 sharp pain to the right shoulder, writer administere
what is documented?
- Assessment findings
- Diagnosis, often included in the plan of care
- Implementations of interventions and evaluations of such
: documents timely (7) and appropriate reports of assessments, decisions about client status, plans, interventions and client outcomes (BCCNM competency in standard 2: knowledge-based practice)
AKA. Charting
→ Communication
→ Safe & appropriate care
→ Professional & legal standards
: Protect yourself; but also ensure to protect other HCP through charting properly and safely
(nurses don’t like to be mentioned on charts e.g. their names)
examples of documentation
- 24 hour flow sheet
- Narrative nursing notes
○ Charting by exception
○ DAR-Data (assessment data), action (nursing intervention), response (evaluation)
○ Nursing care plans
○ Graphic sheets (vital signs)
○ Medication administration records (MARs)
→ Anything heard, seen, felt, or smelled should be reported accurately- Be objective
- Avoid adding in your personal judgements
→ Subjective client information should be placed in quotation marks - Client reports “sharp” abdominal pain
→ Accurate terminology and abbreviations must be used - Only approved abbreviations should be used
If a client has a fall a safety report is completed. What is the purpose of this safety report?
1. To have proper document in case of a law suit
2. To be a permanent part of the client’s record (your response)
3. To inform family/ caregivers of what happened
4. To support quality improvement
- To support quality improvement
In which circumstances would a nurse document the MOST frequently
1. When a client is acutely ill
2. When a client is being discharged from the hospital
3. When a client is first admitted to the hospital
4. When a client has had a fall (your response)
- When a client is acutely ill
In which stage of the nursing process is documentation completed?
1. Assessment and planning
2. Implementation and evaluation
3. Assessment, planning
4. All of the stages (your response)
- All of the stages (your response)
During a morning assessment there is a situation with a client. Which of the following statements would be MOST appropriate?
1. Client became angry and frustrated with the nurse
2. Client was non-compliant and did not listen to the nurse
3. Client stated “get the fuck out of my room and leave me alone” (your response)
4. Client wanted to be left alone
- Client stated “get the fuck out of my room and leave me alone” (your response)
In which of the following situations is a nurse permitted to document care provided by another health care provider?
1. a client has a fall and another nurse helped them back to bed
2. a client is unresponsive and having a seizure and another nurse administered medications
3. a client resturned from surgery and another nurse changed their intravenous bag over
4. a client refused to take their medications from another nurse
- a client is unresponsive and having a seizure and another nurse administered medications
