Nursing Assessment Framework Quiz

Assessment

• Nurses perform ongoing assessments throughout the nursing process to establish a database.
• Nursing history is used to understand the patient's health status, strengths, health problems, health risks, and the need for nursing care.
• Nurses may also conduct a physical examination to collect crucial data.

Types of Nursing Assessments

• First Assessment: Performed after patient admission to build a complete database for problem identification and care planning. Data collected includes patient health history and priorities for ongoing assessments, as well as future comparisons.
• Focused Assessment: A specific assessment centered on an identified problem. Includes targeted questions about symptoms, onset, factors that improve or worsen symptoms, and the use of any remedies.
• Emergency Assessment: Performed during a physiologic or psychological crisis to identify life-threatening problems . Examples include choking, bleeding, and unresponsive patients.

Data Collection

• Data are collected from a variety of sources but require structured collection methods.

• Gordon's framework categorizes functional health patterns to organize data.

• Maslow's hierarchy of needs provides a framework to prioritize patient needs

• Data collection involves gathering both subjective and objective information.

• Subjective data: Perceptions only experienced by the individual (symptoms). Examples include feelings of nervousness, nausea, or coldness.

• Objective data: Observable and measurable data by others. Examples include elevated temperature, skin moistness, or refusal to eat.

• Examples of objective and subjective data are shown in the notes for a 32 year old patient

Data Collection - Characteristics

• Purposeful: Nurses determine the purpose of the assessment (e.g., complete, focused, emergency). Appropriate data gathering follows
• Complete: Gathering as much patient data as needed to understand the health problems and develop a care plan to maximize well-being.
• Factual and Accurate: Accurate description of patient's behaviors and observed conditions is essential for effective care.
• Sources of Data:
  • Patient
  • Family and significant others
  • Patient records, including medical history, physical examinations, progress notes, consultation reports, and lab/diagnostic study results.

Data Interpretation and Analysis

• Experienced nurses begin interpreting data during collection, not just afterward.
• Identifying cues (significant data influencing analysis) and patterns is crucial.
• Significant data should highlight potential problems or concerns.
• Recognizing normal vs non-normal physiological ranges assists in identification of pertinent data, including physiological, affective, and psychomotor outcomes.

History of Nursing Diagnoses

• The term "nursing diagnosis" emerged in the 1950s and evolved over time.
• Initially, the focus in nursing was on actions rather than diagnoses.
• Modern nursing practice identifies and defines specific patient problems.

Nursing Diagnoses vs Medical Diagnoses

• Medical diagnoses identify diseases, whereas nursing diagnoses focus on the unhealthy responses to health.
• Nursing diagnoses provide a description of patient problems nurses can independently treat; medical diagnoses describe disease states, are primarily for physician treatment, and often remain constant. (while nursing diagnoses may change).
• Examples of nursing and medical diagnoses for myocardial infarction, as well as cerebrovascular attack are presented in the notes

Formulating and Validating Nursing Diagnoses

• NANDA recognizes five types of nursing diagnoses: actual, risk, possible, wellness, and syndrome.
• Actual diagnoses indicate definite problems with defining characteristics.
• Risk diagnoses identify potential problems to prevent development of a problem.
• Possible diagnoses highlight suspected problems needing more data for confirmation.
• Wellness diagnoses focus on health promotion and readiness for enhanced coping.
• Syndrome diagnoses combine clusters of actual or risk nursing diagnoses that present as a result of a particular event or situation.

Planning Nursing Care

• Once diagnoses and problems are defined, a plan of care is developed, and the process follows.
• Outcome identification and planning involves setting priorities, identifying patient-centered goals, expected outcomes, and prescribing individualized nursing interventions.
• Planning nursing care requires critical thinking for decision making and problem solving and requires collaboration among patient, family, and team.

Unique Focus of Nursing Outcome Identification and Planning

• The overarching goal of a nursing plan is to resolve, or prevent problems and reduce problems or improve a patient's health.
• Outcomes are written within the plan of care and are used to monitor the patient's progress

Identifying Nursing Interventions

• Interventions are actions a nurse takes to improve patient outcomes.
• Interventions are either independent, which a nurse does on their own; dependent, which require a physician’s order; or interdependent, which requires multiple members of the healthcare team.
• Interventions should be detailed with measurable outcomes that can demonstrate a reasonable path to that outcome

Implementing the Plan of Care

• Implementing the plan of care involves carrying out interventions in a manner that respects the patient's choices, needs, preferences, and culture.
• The nurse should carefully assess the patient's needs and current condition to see if adjustments of the plan of care are needed.
• The plan of care needs to include clear processes, and readily available resources to ensure the care plan can be followed and completed appropriately.

Evaluating

• Evaluating the plan of care involves monitoring the patient’s responses to the care plan.
• Based on the patient’s response, the plan of care may be terminated, modified, or continued.

Types of Outcomes

• These are the measurable results a patient is expected to achieve following a course of care.
• Cognitive (e.g., increased knowledge), Psychomotor (e.g., demonstrating a skill), Affective (e.g., expressing feelings), and Physiologic (e.g., stable vital signs).
• Time criteria must also be included to measure achievement of an outcome.

Documenting Judgments

• After the nurse interprets data relating to the patient outcomes, the nurse should document the findings to determine how effectively the plan of care improved the patient’s outcomes.

Modifying the Plan of Care

• Modifying the plan of care is necessary when outcomes are not being met after the nurse verifies patient responsiveness.
• The plan of care may need revision: if a diagnosis or outcome is deleted or modified or requires a more realistic approach to outcomes, more specific criteria or change to nursing interventions, or modifications of the time criteria related to outcomes.

Establishing Priorities

• Nurses prioritize by using guidelines for ranking diagnoses (e.g., high, moderate, low) based on the threat to patient well-being that diagnoses present
• Prioritizing is also guided by Maslow's hierarchy of needs as well as by patient preferences and the anticipated difficulties a patient may experience as a result of treatment

Test your knowledge on Gordon's framework and various types of data in nursing assessments. This quiz covers key concepts such as subjective versus objective data, primary sources of information, and documentation relevant to nursing practices. Enhance your understanding of comprehensive nursing assessments and best practices.