Foundations - Assessing Notes

Chapter 11: Assessing  Assessing is the systematic and continuous collection, analysis, validation, and communication of patient data or information.  These data reflect how health functioning is enhanced by health promotion or compromised by illness and injury.  Assessment is the first of six nursing standards, COLLECTING patient data is a vital step in the nursing process because the remaining steps depends on purposeful, prioritized, complete, systematic, accurate, and relevant data.  The initial nursing assessment results in baseline data that enable nurse to: o Make a judgment about an individual’s health status, ability to manage his or her own need or self-care and need or nursing care. o Plan and deliver thoughtful, person-centered nursing care that draws on the INDIVIDUAL’S STRENGTHS AND PROMOTES OPTIMUM FUNCTIONING, independence, and well-being.  In addition to an initial assessment of the patient, the nurse makes ongoing assessments.  During the assessment step of the nursing process, the nurse establishes the database by interviewing the patient to obtain a NURSING HISTORY. o Nursing History identifies the patient’s health status, strengths, health problems, health risks, and need or nursing care. o The nurse may also perform a nursing physical examination to collect data.  Other sources of patient information used by the nurse include the patient’s family and significant others, the patient record, other health care professionals, and nursing and other health care literature.  QUESTIONABLE DATA ARE VERIFIED (VALIDATED) AS PART OF THE ASSESSMENT STEP OF THE NURSING PROCESS.  In addition to collecting data, nurses might use intuition to assess patients Unique Focus of Nursing Assessment  When nurses make nursing assessments, they do not duplicate medical assessments  Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient’s responses to health problems. o For example, is there interference with the patient’s ability to meet basic human needs? Can the patient perform the activities of daily living?  Although the findings from a nursing assessment may contribute to the identification of a medical diagnosis, the unique focus of nursing assessments is on the patient’s responses to actual or potential health problems. Assessment and Clinical Reasoning  Since the entire nursing process rests on the initial and ongoing assessment of the patient, it is imperative to use excellent critical thinking and clinical reasoning skills when gathering, analyzing, validating, and communicating data.  To promote sound clinical reasoning, your nursing assessments should have the following characteristics: o Purposeful: When preparing or data collection, identify the purpose of the nursing assessment (comprehensive, focused, emergency, time-lapsed) and then gather the appropriate data. o Prioritized: It is essential to get the most important information first. o Complete: As much as possible, identify all the patient data needed to understand a patient health problem and develop a plan of care to maximize the patient’s health and well-being o Systematic: Using a systematic way to gather data, you will always know if you’ve missed something important. o Factual and accurate: Both the patient and the nurse may intentionally or unintentionally misrepresent or distort patient information. Nurses concerned with accuracy and actual reality continually verify what they hear with what they observe, using other senses and validating all questionable data.  At the outset of data collection, it is crucial to determine whether the patient or caregiver who is supplying the data is reliable. If nurses suspect that their own personal bias or stereotyping may be in influencing their data collection, they should consult with another nurse. o Relevant: Because recording comprehensive data can be very time consuming, one challenge facing nurses is to determine what types of and how much data to collect or each patient. Assessment and Interpersonal Competence  The patient’s initial impression of the nurse is crucial, especially with patients who are new to the health care environment   The patient may judge all nurses encountered in the future in light of this first impression When the nurse communicates respect and genuine concern or the patient, the patient is encouraged to discuss health concerns and problems freely.  The nurse’s competence and professionalism as well as the interpersonal qualities of being respectful and caring invite the patient’s confidence and assure the patient that help is available Types of Nursing Assessments  1. Initial Assessment = Performed shortly after the patient is admitted to a health care agency or service. o The purpose of this assessment is to establish a complete database or problem identification and care planning. o The nurse collects data concerning all aspects of the patient’s health, establishing priorities or ongoing focused assessments and creating a reference baseline for future comparison.  2. Focused Assessment = Nurse gathers data about a specific problem that has already been identified. o Focused Assessment Questions include:  1. What are your signs and symptoms?  2. When did they start?  Were you doing anything different than unusual when they started?  Are you taking any remedies for your symptoms? o Quick priority assessments (QPA) are short, focused, prioritized assessments you do to gain the most important information you need to have first.  3. Emergency Assessment = When a physiologic or psychological crisis presents, the nurse performs an emergency assessment to identify life threatening problems. o Example: A long-term care facility resident who begins choking in the dining room, a bleeding patient brought to the emergency department with a stab wound, an unresponsive patient in the rehabilitation unit.  4. Time-Lapsed Assessment = Is scheduled to compare a patients’ current status to the baseline data obtained earlier. o Most patients in residential settings and those receiving nursing care over longer periods of time, such as homebound patients with visiting nurses, are scheduled or periodic time-lapsed assessments to reassess their health status and to make necessary revisions in the plan of care. Structuring the Assessment  Because many different types of data are collected about patients, data collection must be structured systematically.  Systematic guidelines specifically developed, or a nursing assessment help ensure that comprehensive, holistic data are collected or each patient and lead easily to formulating nursing diagnoses  Most schools of nursing and health care institutions have a MINIMUM DATA SET that specifies the information that must be collected from every patient and uses a structured assessment form to organize or cluster this data.  Maslow hierarchy of five levels of human needs may also be used to organize data.  There are two types of data: SUBJECTIVE and OBJECTIVE. Collecting Data  SUBJECTIVE DATA are information perceived only by the affected person; these data cannot be perceived or verified by another person o Examples of subjective data are feeling nervous, nauseated, or chilly, and experiencing pain.  Subjective data also are called SYMPTOMS or COVERT DATA.  OBJECTIVE DATA are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them. o Objective data observed by one person can be verified by another person observing the same patient o Examples of objective data are an elevated temperature reading (101°F), skin that is moist, and refusal to look at or eat food. Sources of Data  PATIENT is the primary and usually the best source of information.  Family and Significant Others: Family members, friends, and caregivers are especially helpful sources of data when the patient is a child or has limited capacity to share information with the nurse.  Patient Record: Records prepared by different members of the health care team provide information essential to comprehensive nursing care. The nurse should review records early when gathering data—in some instances, before the first contact with the patient. This review helps to focus the nursing assessment and to confirm and amplify information obtained from other sources. Methods of Data Collection   Data collection can be taken by Observing, Interviewing, and Examining. OBSERVATION is a key nursing skill when performing both the nursing history and the physical examination  OBSERVATION is the conscious and deliberate use of the five senses to gather data  The nurse obtains the nursing history by INTERVIEWING the patient.  INTERVIEW is a planned communication.  Physical assessment is the EXAMINATION of the patient or objective data that may better determine the patient’s condition and help the nurse plan care. o Unlike the physical assessment performed by the physician to identify pathologic conditions and their causes, the nursing physical assessment focuses primarily on the patient’s functional abilities. Physical Assessment (Extra info)  The nursing physical assessment involves the examination of all body systems, called the review of systems (ROS), in a systematic manner, commonly using a head-to-toe format.  Four methods are used to collect data during the physical assessment: inspection, palpation, percussion, and auscultation. Validating Data  Validation is the act of confirming or verifying.  The purpose of validating is to keep data as free from error, bias, and misinterpretations as possible. Data need to be verified when there are discrepancies: a patient tells you he is fine and has no concerns, but you note that he demonstrates tense body musculature and seems curt in his responses.  When there is a discrepancy between what the person is saying and what you are observing, validation is necessary to determine accuracy.  Data also need verification when they lack objectivity. o For example, you suspect that the patient hears in one ear but does not seem to hear well in the other. You should validate the data before proceeding and should determine whether the patient does indeed have a hearing problem  Validation is an important part of assessment because invalid information can lead to inappropriate nursing care. Documentation  The patient’s initial database is entered into the computer or recorded in ink, using the designated agency protocol or forms, the same day the patient is admitted to the agency.  Objective and subjective patient data should be summarized and written so that the data communicate a unique sense of the patient and are comprehensive, concise, and easily retrievable.  The data should be written legibly, using good grammar and only standard medical abbreviations.  Subjective data should be recorded using the patient’s own words within quotation marks: “I feel tired from the moment I first get up in the morning. It seems I have no energy at all.” o Patient reports may also be paraphrased.  Avoid the tendency to record data using nonspecific terms with different meanings or interpretations - words like adequate, good, average, normal, poor, small, large. o One nurse’s idea of what “average” fluid intake is may be very different from that of another nurse.