If the data collection is inadequate or inaccurate, incorrect nursing judgement may be made that could adversely affect the remaining phases of the process.
Enumerate the Phase of the Nursing Process.
ADPIE
Assessment
Diagnosis
Planning
Implementation
Evaluation
Collecting subjective and objective data.
Assessment
Analyzing subjective and objective data to make professional nursing judgements.
Diagnosis
Determining the outcome criteria and developing a plan.
Planning
Carrying out the plan.
Implementation
Assessing whether outcome criteria have been met and revising the plan as necessary.
Evaluation
The purpose of nursing health assessment.
to collect subjective and objective data to determine a client's overall level of functioning in order ro make professional clinical judgement.
Using ______ helps to organize information and promote the collection of holistic data.
nursing framework
What are the 4 basic types of assessment?
1.Initial comprehensive assessment
2.Ongoing or partial assessment
3.Focus or problem-oriented assessment
4.Emergency assessment
An assessment, which involves collection of subjective and objective data from the patient.
Initial comprehensive assessment
What are the datas needed to be collected in an initial comprehensive assessment?
1. Client's perception of their health, of all the body parts or systems.
2.Past health history
3. Family history
4.Lifestyle
5.Health practices and
6.Objective data gathered during physical examination (done by medical practitioners
It establishes the baseline data against which future health status changes can be measured and compared.
Initial comprehensive assessment
This assessment is done after the comprehensive data baste is established. Consists of a mini-overview of the client's body systems and holistic health patterns as a follow up on his health status.
Any problem that were initially detected in client's body system or holistic health patterns are reassessed in less depth to determine any major changes from the baseline data.
Ongoing or partial assessment
It is performed when the comprehensive database exists for a client and she comes to a healthcare agency with a specific health concern.
Consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem.
Focus or Problem-oriented assessment
A very rapid assessment performed in life-threatening situations. An immediate diagnosis is needed to provide prompt treatment. The major and only concern during this type of assessment is to determine the status of the client's life-sustaining functions.
Emergency assessment
An example of emergency assessment when cardiac arrest is suspected.
ABC or the Airway, Breathing and Circulation
What are the 4 major steps of the assessment phase?
1. Collection of subjective data
2. Collection of objective data
3. Validation of data
4.Documentation of data
Although there are 4 steps, they tend to overlap and may perform two or three steps concurrently.
Step 1 of the nursing assessment phase.
Preparing for the assessment.
In preparing for the assessment process the nurse should:
1. Review the client's records if available.
2.Knowing the client's biographical data could be helpful.
3. Also useful is documented information regarding client's medical diagnosis and progress notes.
4.Keep an open mind and avoid premature judgements that may alter your ability to collect accurate data.
5. Use this time to educate yourself about the client's diagnosis or test performed. The client may have a medical diagnosis that you have never heard of or that you never dealt with in the past.
6.Take a minute to reflect on your own feelings regarding your initial encounter with the client.
7. You must be objective and open as possible.
8.Obtain and organize materials that you will need for the assessment. Also gather any equipment.
It is a type of data that is based on the sensation, symptoms, feelings, perception, desires, preferences, beliefs, ideas, values and personal information that can be elicited and verified only by the client.
Subjective data
The major areas of subjective data includes:
1.Biographical information
2.Physical symptoms related to each body or system
3.Past health history
4.Family history
5.Health and lifestyle practices.
Objective data are
directly observed by the examiner
Objective data includes what?
Physical characteristics
Body functions
Appearance
Behavior
Measurement
Results of laboratory testing
Objective data is obtained by general observation and by using the 4 physical examination techniques. What are those techniques?
Inspection
Palpation
Percussion and
Auscultation
It serves to ensure that the assessment process is not ended before all relevant data have been collected and it helps prevent documentation of innacurate data.
Validating assessment data
This step of the nursing assessment is important because it forms the database for the entire nursing process and provides data for all other members of the health care team.
It is vital to ensure valid conclusions are made when the data are analyzed in the second step of the nursing process.
Documenting Data
The second phase of the nursing process.
Analysis of data or often called diagnosis
What is the purpose of assessment?
To arrive at conclusions about the clients health
is a clinical judgement about individuals, family or community responses to actual and potential health problems and life processes.
provides the basis for selecting interventions to achieve outcomes for which the nurses is accountable.
Nursing diagnosis or nusrsing concern
Nurses manage this type of data by implementing both physician and nurse prescribed intervention to reduce further complications.
Collaborative problems
often occurs because nurses assess the whole client and often identify problems that require the assistance of other health care professionals.
Referral
This nursing process requires critical thinking to arrive at a conclusion about the client's health.
Diagnosis
What are the steps of nursing diagnosis.
1.Identify abnormal data and strengths
2.Cluster the data
3.Draw the interferences and identify problems
4.Propose possible nursing diagnoses
5.Check for defining characteristics of those diagnoses.
6.Confirm or rule out nursing diagnoses
7.Document conclusions.
Sensation or symptoms
Subjective data
Feelings
Subjective Data
Perception
Subjective Data
Desires
Subjective Data
Preferences
Subjective Data
Beliefs
Subjective Data
Ideas
Subjective Data
Values
Subjective Data
Personal Information
Subjective Data
Information is obtained through (a)
Obtaining a valid nursing health history requires professional, interpersonal and (a.) skills.
interview
interviewing
What are the 2 focuses of the nursing interview?
1.Establishing rapport and trust.
2.Gathering information on client's statuses to identify deviations that can be treated with nursing and collaborative interventions or strengths that can be enhanced through nursing interventions.
What are the phases of the interview?
Introductory working and summary
After introducing himself to the client,
1.the nurse explains the purpose of the interview,
2.discusses the types of questions that will be asked,
3.explains the reason for taking notes and
4.assures the client that confidential informations will remain confidential.
5. the nurse also make sures that the client is comfortable (physically and emotionally) and has privacy
Introductory Phase
the nurse explains the purpose of the interview
introductory phase
discusses the type of questions that will be asked
introductory phase
explains the reason for taking notes
introductory phase
assures the client that confidential information will remain confidential
introductory phase
The phase where establishing rapport and trust is essential.
Introductory phase.
This can begin by conveying a sense of priority and interest in the client.
During this phase the nurse elicits the client's comment about major biographic data,
reasons for seeking care,
history of present health concern,
past health history,
family history,
review of body systems for current health problems,
lifestyle and health practices.
The nurse then listens, observes cues and uses critical thinking skills to interpret and validate information received from the client. THE NURSE AND CLIENT COLLABORATE TO IDENTIFY THE CLIENT'S PROBLEMS AND GOALS.
Working Phase
During this phase the nurse summarizes information obtained during the working phase and validates problems and goals with the client.
She also identifies and discusses possible plans to resolve the problem with the client and finally the nurse makes sure to ask if anything else concerns the client and if there are further questions.
Summary and Closing Phase
Appearance
Nonverbal
Demeanor (outward behavior
nonverbal
posture
nonverbal
facial expression
nonverbal
attitude
nonverbal
_____ communication is important because it can also influence how the client perv=ceive the questions you ask. NEVER OVERLOOK THIS TYPE OF COMMUNICATION OR TAKE IT FOR GRANTED.
Nonverbal communication
Appearance, demeanor should be kept ______.
Professional.
Wear comfortable, neat clothes and a laboratory coat or a uniform. Your hair should be neat and not in any extreme style,fingernails should be short and neat, jewelry should be minimal.
Display poise. Do not enter the room laughing loudly, yelling to a coworker, or muttering under your breath. Do not be overwhelmingly friendly or touch. Maintain a professional distance.
Often overlooked aspect of the communication.
Facial expression- shows what you are truly thinking.
Always keep your expression neutral and friendly. But that doesn't mean that your face lacks expression. It means using the right expression at the right time.
If you cannot effectively hide your emotions, you may want to explain that you are angry or upset about a personal situation.Admitting this to the client may help in developing a trusting relationship and genuine rapport.
One of the most important nonverbal skills to develop as a health care professional is a nonjudgmental attitude. TRUE or FALSE
VERY TRUE
All clients should be accepted regardless of of beliefs, ethnicity, lifestyle and health care practices.
Do not act superior to the client or appear shocked, disgusted or surprised at what you are told.
Accept the client, be understanding of the habits and work together to improve the client's health.
For example you're interviewing a client who smokes. Avoid lecturing the client about the dangers of smoking.Avoid telling the client he or she is foolish or portraying an attitude of disgust.However this doesn't mean that you should not encourage the client to quit. Let the client know you understand that it is hard to quit smoking, support efforts to quit and offer suggestions to help kick smoking.
YOUR APPROACH IN THE SITUATION MATTERS.
Allows you and the client to reflect and organize thoughts, which facilitates more accurate reporting and data collection.
Silence
The most important skill to learn and develop fully in order to collect complete and valid data from your client.
Listening
In order to listen effectively you must:
Maintain good eye contact,smile or display an open, appropriate facial expression, maintain an open body position. Keep an open mind and concentrate on the concern of the patient.
Avoid crossing your arms,sitting back,tilting your head away from the client, thinking about other things or looking blank or inattentive.
TRUE OR FALSE?
Nonverbal ques or attitude may hinder effective communication.
TRUE. They may promote discomfort or distrust.
What are the nonverbal communication to avoid?
1.Excessive or Insufficient Eye Contact
2.Distraction and distance
3.Standing
Present right or proper procedure in comparison to the following:
Having excessive or insufficient eye contact
Use moderate amount of eye contact.
Present right or proper procedure in comparison to the following:
Distraction and distance
Avoid being occupied with something else while you ask questions during their interview.Avoid appearing mentally distance as well. Also try to avoid physical distance during interview, the client will less likely to answer your question.
Present right or proper procedure in comparison to the following:
Standing
Avoid standing for puts you and the client at different levels. You may be perceived superior making your client inferior.
What are the verbal communications to avoid?
1.Biased or Leading Questions
2.Rushing through the interview
3.Reading questions
Present right or proper procedure in comparison to the following:
Biased or Leading Questions
The way you phrase a question actually lead the client to behave in a certain way. Let the client express there thoughts about your questions.
Present right or proper procedure in contrast to the following:
Rushing through the interview
Taking time with client shows that you are concerned about their health and helps them to open up.
Rushing someone through the interview process undoubtedly causes important information to be left out of the health history.
Present right or proper procedure in contrast to the following:
Reading the questions
Avoid reading the questions from the history form. This deflects attention from the client and results in impersonal interview process. As a result the client may feel ill at ease opening up to formatted questions.
Questions used to elicit the client's feelings and perception. Usually begins with "how" or "what". These type of questions are important because they require more than one-word response from the client and therefore, encourage description.
It may help reveal significant data about the client's health status.
Open-ended questions
This type of questions obtain facts and focus only at a specific information. The client can respond in one or two words. It typically begins with words like "when" or "did".
It is useful for keeping the interview on course.They can be used to clarify or obtain more accurate information about issues disclosed in response to open-ended questions.
Example:
"How have you been feeling lately", the client says, "Well, I've been feeling really sick at my stomach and I don't feel like eating because of it."
You may be able to follow up and learn more about the client's symptoms with a close-ended questions such as "When did the nausea start?"
Close-ended questions
Another way of asking questions that provides the client with choices of words to choose from in describing symptoms, condition or feelings.
Laundry list
Author
wyn
ID
360777
Card Set
Chapter 1-Conceptual Overview of Nursing Health Assessment
