Nursing Assessment Techniques Quiz

Assessment of Nursing Diagnosis

• Nurses perform ongoing assessments throughout the nursing process, establishing a database.
• Nursing history collects patient details, strengths, health issues, risks, and the need for nursing care.
• A nursing physical examination may also be conducted to gather data.

Types of Nursing Assessments

• First Assessment: Conducted after admission, creating a comprehensive database for problem identification and care planning. Data collection includes patient's health status, priorities, and for future comparisons.
• Focused Assessment: Data collection on a specific, already identified problem. Useful questions include: What are the symptoms, when did they start, were there changes in lifestyle when they started, what makes symptoms better or worse, and remedies used (medical/natural)? Focused assessment is commonly used for ongoing data collection, helping identify new or overlooked problems.
• Emergency Assessment: Used during physiological or psychological crises to identify life-threatening problems. Includes situations such as choking, bleeding, or unresponsive patients.
• Time-Lapsed Assessment: Scheduled to compare a patient's current status with earlier baseline data, often used for taking vitals every four hours.

Data Collection

• Data collected about patients is structured to be systematically collected.
• Using assessment guidelines, it's easier to focus on the patient during the assessment.
• Gordon's framework identifies functional health patterns and organizes patient data.
• Maslow's hierarchy of five sets of human needs is used as a guide.

Types of Data

• Subjective data: Information perceived only by the affected person; feelings, pain, nausea, or chills.
• Objective data: Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing it; elevated temperature, moist skin, refusal to eat/drink.

Data Collection Characteristics

• Purposeful: The nurse specifies the assessment type (e.g., comprehensive, focused, emergency, time-lapsed).
• Complete: All relevant patient data is collected to understand the health problem.
• Factual and Accurate: Observed behaviors are described precisely and accurately.

Sources of Data

• Patient: Primary source of information.
• Family and Significant Others: Helpful when the patient is a child or has limited capacity to communicate.
• Patient Record: Includes medical history, physical examinations, progress notes, lab results, and reports from other healthcare professionals.
• Consultations: Physician consultations with specialists regarding patient care.
• Nursing and Other Healthcare Literature: Relevant information from nursing and other medical resources for a comprehensive overview.

Methods of Data Collection

• Nursing History: Obtained as soon as possible after a patient presents for care. Includes strengths and weaknesses, health risks (e.g., hereditary/environmental factors), and existing/potential problems.
• Patient Interview: A planned communication process between the nurse and the patient to obtain nursing history. Strong interviewing skills are essential for successful partnerships.
• Nursing Physical Assessment: Exam of the patient to find objective data regarding the current condition and assist with care planning. The assessment usually follows the nursing history, and may validate, or add new, data.

Data Reporting and Recording

• Patient data collected by the nurse should be shared with other healthcare professionals.
• Timing is important: report critical changes in patient health status immediately. Use the necessary documentation formats/forms.

Diagnosing

• Collecting data, identifying cues, validating data, organizing/clustering data, identifying patterns, reporting and recording data, and then interpreting data to develop a list of suspected problems/diagnoses.
• Ruling out similar problems/diagnoses.
• Naming actual and potential problems/diagnoses, and clarifying what's contributing to them.
• Determining risk factors.
• Identifying resources, strengths, and areas for health promotion.

History of Nursing Diagnoses

• The term "nursing diagnosis" appeared in literature around 1950.
• The ANA's Nurse Practice Act (1955) excluded diagnosis or prescriptive therapies.
• In 1973, the first conference on nursing diagnosis defined 80 nursing diagnoses. Now, there are around 300.
• The North American Nursing Diagnosis Association (NANDA-I) is an ongoing research body focusing on nursing diagnosis.

Nursing Diagnosis vs. Medical Diagnosis

• Medical diagnoses identify diseases, while nursing diagnoses focus on unhealthy responses to health and illness.
• Nursing diagnoses describe patient problems that nurses can treat independently. Medical diagnoses describe problems for which physicians have primary treatment responsibilities.

Data Interpretation and Analysis

• Experienced nurses begin analyzing data simultaneously with the collection/assessment process. Significant data is denoted by 'cues'.
• Significant data should be highlighted/identified
• Recognizing patterns in data is key for developing nursing diagnoses.
• Identifying strengths and problems is part of analyzing patient data.
• Identifying potential complications also forms part of data analysis.
• Reaching conclusions about the patient's health status based on data interpretation, whether the patient has no problem, a possible problem, or an actual/potential nursing diagnosis.

Formulating and Validating Nursing Diagnoses

• NANDA identifies five types of nursing diagnoses: actual, risk, possible, wellness, and syndrome.
• Actual nursing diagnoses describe existing problems, and their defining characteristics.
• Risk nursing diagnoses identify vulnerability to developing a problem.
• Possible nursing diagnoses suggest a suspected problem requiring more data.
• Syndrome diagnoses are clusters of actual/risk diagnoses indicating a predictable outcome.

Implementing the Plan of Care

• Nurses use their skills to determine patients' needs.
• They organize the resources for patient care and ensure patients are prepared psychologically and physically.
• Encourage patient independence but provide assistance where necessary.
• This step involves organizing equipment and the right environment.
• Includes promoting self-care, teaching, counseling, and advocacy.

Evaluating

• The nurse measures the patient's achievement of outcomes.
• Outcomes are evaluated based on patient responses to the care plan to determine whether to terminate the plan, modify the plan, or continue the plan.
• Types of outcomes are Cognitive, Psychomotor, Affective, Physiologic.

Time Criteria

• Nurses use time criteria to determine when to collect and evaluate data during patient care.
• It also helps determine the best times to assess patient outcomes.

Modifying the Plan of Care

• If outcomes aren't met, the plan of care can be modified by either deleting or modifying a diagnosis, or changing intervention, or modifying timing/complexities.

Types of Nursing Interventions

• Independent: Nurse-initiated, doesn’t require physician input.
• Dependent: Physician-initiated, requires a physician's order.
• Interdependent: Collaborative, needs multiple healthcare professionals from different fields.

Establishing Priorities

• Ranking diagnoses as high, medium, or low, considering threat to well-being, health problems, and patient's needs.
• Use Maslow's Hierarchy of Needs to understand what basic needs could come first.
• Consider patient preference, and anticipate future problems that could pose a risk.

Test your knowledge on various nursing assessment techniques used during patient admission and monitoring. This quiz covers focused, time-lapsed, and ongoing assessments, including their purposes and goals. Enhance your understanding of systematic data collection in nursing practice.