Introduction to Health Assessment

Steps of the Nursing Process Assessment The nurse gathers the client’s information through an interview, physical exam, and observation. Roles ● RN: Maintains an ongoing knowledge of assessment techniques and best practices ● PN: Assist the RN by systematically collecting data, reviewing information about the client, and communicating it to the RN and appropriate members of the healthcare team Collected Data ● Subjective Data: The client’s reason, usually physical symptoms, for visiting the provider ● Objective Data: The nurse’s observations or measurements of a client’s health condition Analysis ● ● ● Only involves RNs Analyze the subjective and objective data collected during assessment using clinical judgment Collaborates with the client to develop a plan of care, identifying actual and potential problems Planning Uses evidence-based practice (EBP): planning and provision of care supported by research, clinical experience, practice trends, and client preferences. Roles ● ● RN: Uses problem-solving and decision-making skills to prioritize care ○ Goals are set and agreed upon between the RN, client, and possibly the family PN: Assist the RN in the development of expected outcomes and interventions Implementation ● ● RN: Carries out interventions that have been established ○ Uses clinical judgments to monitor the client’s progress ○ Determines the best approach to promote client learning PN: Providing planned care to accomplish expected outcomes Evaluation Roles ● ● RN: Evaluates the effectiveness of the goals and the need for adjustment of the interventions PN: Compare the actual outcome of nursing care to expected outcomes Critical Thinking and Clinical Judgment Contextual Awareness ● Understanding the status of the client and events that have led to their need for healthcare Analyzing Assumptions ● Evaluating the client’s clinical situation and critical thinking ● To use or modify standard approaches to meet a client’s specific health needs/concerns Exploring Alternatives ● The use of holistic approaches for treating the whole person ● Each client’s health needs are unique and are a culmination of SDOHs Credible Sources ● Using facility standards, such as standards from The Joint Commission Reflecting and Deciding ● Self-reflection from the nurse and reflection on the client goals ● Deciding on the interventions with client input Ethical Principles Nonmaleficence ● To do no harm ● First and foremost in healthcare Beneficence ● To promote the good of the client ● The ultimate goal is a return to health/homeostasis Autonomy ● The client’s right to make decisions, such as refusing treatment ● The client must have the mental capacity to act and decide on their own behalf Justice ● To treat everyone regardless of their ability to pay for treatment, social status, gender identity, or cultural/religious background Confidentiality ● Respecting the rights of the clients to maintain privacy ● Health Insurance Portability and Accountability Act (HIPAA): A law that establishes public standards regarding how, with whom, and when health information can be shared Communication Skills Personal Factors ● Maintain professionalism with all communications ● Practice empathy by putting yourself in the client’s situation Therapeutic Communication Introduce yourself and state your title. Ensure that your badge remains visible for reference. Focus on the person, not the problem. Things to avoid in therapeutic communication: ● Using inappropriate plural pronouns (“we”) ● Assuming the client knows about a health interview/physical ● Asking irrelevant, personal questions ● Giving personal opinions ● Using automatic responses and false reassurances ● Relaying disapproval of client statements or practices Verbal ● Ask what the client prefers to be called, otherwise address them by their surname ● Ask which personal pronouns they use and use inclusive terms, such as “partner” ● ● ● ● ● ● ● ● Keep questions focused and relevant Ask open-ended questions Redirect the client as needed Engage in active listening Restate the client’s view to indicate understanding Use everyday language and stay away from medical terms Keep emotionally charged conversations for last Give positive reinforcement and reassurance without passing judgment or disapproval Nonverbal ● ● ● ● Face the client when speaking Maintain personal space (an arm’s length away) Get permission when intimate distances are needed Use therapeutic touch when appropriate and with permission Expected Variations ● ● ● ● Determine whether alternate or additional communication methods are needed Consider neurodiversity as well as any physical, mental, and sensory limitations Consider the culture of the client when assessing nonverbal communication Be open, respectful, and honest ○ Inform them of any information shared that is required to be reported ● Be certain that the client understands your questions and you understand their answers ● Neurodiversity: The recognition that peoples’ brains can function differently from one another without indicating the presence of a disability ISBARR A tool to have clear communication for effective client care. Identify ● State the team member’s name and title Situation ● Provide the circumstances that have required the communication to occur Background ● Provide the background data regarding the client to assist the provider with familiarity Assessment ● Provide the most recent set of vital signs or other data relevant to the communication Recommendations ● Provide any suggestions that may be helpful to the situation Read Back Orders ● Repeat the orders that are given and clarify anything that is unclear Assessment Techniques Inspection Process ● Looking carefully and thoroughly at a client ○ Observe symmetry; notice skin tone, rashes, bruising, and wounds ● Use olfaction to detect an unusual body odor ● Look at the shape of the chest, facial features, and any deformities ● Inspect and observe the affect and mood of the client ● Each body system should be assessed, but a more thorough, focused examination of one is warranted if an unexpected finding is discovered Tools ● ● ● ● ● ● ● Good light source Source to perform proper hand hygiene Penlight for assessing pupil size and reaction Tape measure to measure wounds, bruising, or abdominal girth Pulse oximeter to determine oxygen saturation Tongue depressor to examine oral mucosa Stadiometer to measure height Auscultation ● Listening to the sounds of the heart, lungs, stomach, intestines, and arteries Tools ● Requires a stethoscope, which should be cleaned in between each client use ○ Diaphragm: Used to listen to high-pitched sounds, including breath, bowel, and expected heart sounds ○ Bell: Used to listen to soft, low-pitched sounds, like extra heart sounds/murmurs ● Use gentle pressure and do not auscultate over clothing ● A doppler is an ultrasound device that uses sound waves to provide sounds Palpation ● The act of using the dorsal surface of the hands and fingertips to feel areas of the body for various findings, like temperature, moisture, or unexpected findings ● When palpating for fluid, crepitus, size, and consistency of masses, use the palmar surfaces of fingers/finger pads, not fingertips ● If checking for a vibration sensation, use the ulnar surface of the hands ● Palpate tender areas last Percussion ● Tapping the client’s skin with a short, quick motion to determine vibrations and sounds ● Can help determine the density of the area, whether it is fluid-filled, air-filled, or solid Documenting Findings The physical/electronic record is a legal document that records the actions healthcare providers complete. Clear, accurate documentation provides a precise/factual account of the client’s status. Included in Documentation ● Medications administered and the client’s response ● Interventions and treatments provided ● Objective and subjective data to reflect the client’s condition How to Document ● ● ● ● ● ● ● Document only after you complete the task, not before Document as close to the time the care was delivered as possible Objective data includes measurement results, behaviors, and the client’s condition When including relevant subjective information, use their exact words in quotes Note the necessary steps used to correct any concerns or complaints Only record facts and avoid unclear jargon such as “appears,” “seems,” or “apparently” Speak concisely and avoid abbreviations unless The Joint Commission accepts them Electronic Records ● Used for documenting the progress, treatments, interventions, and client responses to care ● Be aware of confidentiality issues and the potential for others to see personal information Paper Records ● Properly date and time each entry using military time ● Follow this with a full signature and title ● If an error is made, draw a single line through and initial it