Potter/Perry Chapter 16: Nursing Assessment – Flashcards

A critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness.

Def. Fundamental blueprint for how to care for a patient. "Standard of Practice" 1. Assessment - Collection, verification, and analysis of data. 2. Diagnose - identify the patient's problems 3. Plan- Set goals of care and desired outcomes and id appropriate nursing actions 4. Implement- perform the nursing actions id in planning 5. Evaluate- determine if goals and expected outcomes are achieved

Def. The deliberate and systematic collection of information about a patient to determine his or her current and past health and functional status and his or her present and past coping patterns. Nursing Assessment includes two steps: 1. Collection of information from a primary source (the patient) and secondary sources (e.g. family members, health professionals, and medical record) 2. The interpretation and validation of data to ensure a complete database.

The purpose of assessment is to establish a database about the patient's perceived needs, health problems, and responses to these problems. In addition, the data reveal related experiences, health practices, goals, values, and expectations about the health care system.

Gather information (assessment) to make an accurate judgment about a patient's current condition. Your information comes from: 1. The patient, through interview, observations, and physical examinations 2. Family members or significant others' reports and response to interview 3. Other members of healthcare team 4. Medical records (patient history, labs, x-ray) 5. Scientific Literature (evidence about assessment techniques and standards)

Information that a nurse obtain through the use of the senses (hearing, visual observations, touch, and smell).

Your judgment or interpretation of the cues Example: A patient crying is a cue that possibly implies fear or sadness

Male patient in bed, looks uncomfortable. Patient presents with discomfort in surgical area. Cues - Lies still with arms along sides; tense - States has not turned for some time - Reports pain a 7 on a scale of 0 to 10 Inferences - Pain is severe - Pain limits patient's ability to move and reposition self

An example of a structured database format, one approach to perform a comprehensive assessment. Gordon's functional health patterns model offers a holistic framework for assessment of any health problem. The health patterns are listed below.

Describes patient's self-report of health and well-being; how patient manages health. Example: frequency of health care provider visits, adherence to therapies at home; knowledge of preventative health practices

Describes patient's daily/weekly pattern of food and fluid intake. Example: food preferences or restrictions, special diet, appetite; actual weight, weight loss or gain

Describes pattern of excretory function. Example: bowel, bladder, and skin

Describes patterns of exercise, activity, leisure, and recreation; ability to perform activities of daily living

Describes patterns of sleep, rest, and relaxation.

Describes sensory-perceptual patterns; language adequacy, memory, decision-making ability

Describes patient's self-concept pattern and perceptions of self. Example: self-concept/worth, emotional patterns, body image

Describes patient's patterns of role engagements and relationships

Describes patient's patterns of satisfaction and dissatisfaction with sexuality pattern; patient's reproductive patterns; premenopausal and postmenopausal problems

Describes patient's ability to manage stress; sources of support; effectiveness of the patterns in terms of stress tolerance

Describes patterns of values, beliefs including spiritual practices, and goals that guide patient's choices or decisions

1. Nature of Pain - Describe your pain for me. Place your hand over the area that hurts or is uncomfortable. Observe nonverbal cues, observe where patient points to pain; note if it radiates or is localized 2. Precipitating factors - Do you notice if pain worsens during any activities or specific time of day? Is pain associated with movement? Observe if patient demonstrates nonverbal signs of pain during movement, positioning, swallowing 3. Severity - rate your pain on a scale from 0 to 10. Inspect area of discomfort, palpate for tenderness.

Subjective data- Patients' verbal descriptions of their health problems. Includes feelings, perceptions, and self-report of symptoms. Once a patient provides subjective data, explore findings further by collecting objective data. Objective data- Observations or measurements of a patient's health status. Be clear, precise and consistent.

Patient- (Best Source) when conscious, alert, and able to answer questions. Family & Significant others- (Primary sources of information for infants or children; critically ill adults; and the mentally handicapped, disoriented, or unconscious) Health Care Team- Medical Records- Medical history, laboratory, diagnostic test results, current physical findings, and the primary health care provider's treatment plan. Other records and Scientific Literature- Educational, military, and employment records

Open-ended questions- prompts patients to describe a situation in more than one or two words. Back Channeling- Active listening technique that prompts a respondent to continue telling a story or describe a situation. Involves use of phrases such as "Go on", "Uh huh", and "Tell me more". Probing- As a patient tells his or her story, encourage a full description without trying to control the direction the story takes. Requires probing with open-ended questions. Closed-ended questions- Limits answers to one or two words such as "yes" or "no" or a number or frequency of a symptom.

Patient-centered Interview: an approach for obtaining from patients the data that are needed to foster a caring nurse-patient relationship, adherence to interventions & treatment effectiveness. 1. Setting the stage- Example: greet using patient by full name, provide privacy, explain reason for collecting history, assure confidentiality 2. Set an agenda- xample: gather info by asking patient about chief concerns or problems, focus on patient 3. Collect the assessment or nursing health history- Example: open-ended questions, use attentive listening, observe verbal cues 4. Terminating the interview- Example: summarize your discussion, give a clue when the interview will end, tell patient when you will return

You gather a nursing health history during either your initial or early contact with a patient. Major part of assessment. Includes biographical information, reason for seeking health care, patient expectations, present illness or health concerns, health history, family history, environmental history, psychosocial history, spiritual health, review of systems, and documentation of history findings.

Factual demographic data about the patient. The patient's age, address, occupation and working status, marital status, source of health care, and types of insurance are included. Admitting office staff usually collects this information.

(aka Chief Concern)This is the information you gather when you initially set an agenda during the patient-centered interview. Compare what you learn from the patient with the "chief complaint", which is often typed on the patient's admission sheet. Ask the patient why he or she is seeking health care, for example, "Tell me, Mr. Lynn, what brought you to the clinic today". You record the patient's response in quotations to indicate the subjective response. Clarification for the patient's perception identifies potential needs for symptom management, education, counseling, or referral to community resources.

Patient's understanding of why he or she is seeking health care. The assessment of patient expectations is not the same as the reason for seeking medical care, although they are often related. Failure to identify a patient's expectations of health care providers results in poor patient satisfaction.

Essential and relevant data about the nature and onset of symptoms. If a patient presents with an illness, collect essential and relevant data about the symptoms and their effects on the patient's health. Apply the critical thinking intellectual standards of complete and deep by assessing these factors: - Location - Where is the symptom located - Onset and duration - When did it start? How long has it lasted? - Precipitating factors - What makes symptoms worse? Are there activities, example: exercise, that affect the symptoms? - Relieving factors - What does the patient do to become more comfortable or relieve the symptoms? - Quality - Have the patient describe what the symptoms feels like - Severity - Have the patient rate the severity on a scale of 0 to 10. This gives you a baseline with which to compare in follow-up assessments. - Concomitant symptoms - Does the patient experience other symptoms along with the primary symptom?, For example, does nausea accompany pain?

Health care experiences and current health habits and lifestyle patterns.

To determine whether the patient is at risk for illnesses of a genetic or familial nature and identify areas of health promotion and illness prevention.

Patient's home and work, focusing on determining the patient's safety.

Reveals the patient's support systems and coping mechanisms.

Represents the totality of one's being.

A systematic approach for collecting the patient's self-reported data on all body systems.

An investigation of the body to determine its state of health. Techniques used: Inspection, palpation, percussion, auscultation, and smell. Examination includes: patient's height, weight, vital signs, and a head-to-toe examination of all the body systems.

You determine the presence of abnormal findings. Recognize that further observations are needed to clarify information. Begin to identify the patient's health problems. The patterns of data reveal meaningful and usable clusters. Data cluster- A set of signs or symptoms that you group together in a logical way.

The comparison of data with another source to determine data accuracy. Compare with unclear interview information and physical examination findings.

Documentation should be timely, thorough, and accurate. Record all observations. Pay attention to facts and be descriptive. Record objective information in correct, accurate terminology. Do not generalize or form judgements.