Assessing Nursing 102 PDF

Assessing Nursing 102  Learning Outcomes  Describe the phases of the nursing process  Identify major characteristic of the nursing process  Identify the purpose of assessing  Identify the four major activities Associated with the assessing phase  Differentiate subjective and obje...

Assessing Nursing 102  Learning Outcomes  Describe the phases of the nursing process  Identify major characteristic of the nursing process  Identify the purpose of assessing  Identify the four major activities Associated with the assessing phase  Differentiate subjective and objective data, and primary and secondary data  Learning Outcomes  Identifythree method of data collection  Compare directive and non- directive approaches to interviewing  Compare close and open ended questions  Describe important aspect to interview setting  Nursing Process  Is a systematic, rational method of planning and providing nursing care.  Purposes of the nursing process: 1. Identify a client’s health status 2. Identify actual or potential health care problems or needs 3. Establish plans to meet the identified needs 4. Deliver specific nursing interventions to meet those needs Components of the nursing process:  Assessing  Diagnosis  Planning  Implementing  Evaluating.  Assessing  Collecting Data  Organizing Data  Validating Data  Documenting Data  Goal: - Establish a database about client response to health concerns or illness - The client may be an individual, a family, or a group. Diagnosing  Analyzing and synthesizing data  Goals:  Identify client strength  Identify health problem that can be prevented or solved  Develop a list of nursing and collaborative problems  Planning  Determine how to prevent, resolve or reduce identified priorities client problems  Determine how to support client strength  Determine how to implement nursing interventions in an organized, individualized and goal directed manner  Goals:  Develop an individualized care plan that specifies client goals\desired outcomes  Related nursing intervention  Implementing  Carrying out and documenting planned nursing intervention  Goals:  Assist clients to meet desired outcomes and goals  Promote wellness  Prevent illness or disease  Restore health  Facilitate coping with altered function  Evaluating  Measuring the degree to which goals\outcomes have been achieved  Identify factors that negatively or positively influence goal achievement  Goal:  Determine whether to continue, modify or terminate the plan of care Characteristic of nursing process  Cyclic and dynamic nature  Client centeredness  Focus on problem solving and decision making  Interpersonal and collaborative style  Universal applicability  Use critical thinking in all phases  Utilize clinical reasoning throughout the delivery of nursing care.  Figure 11–3 Critical thinking, clinical reasoning, and the nursing process. Assessment  Is the systemic and continuous collection, organization, validation, and documentation of data (information)  All phases of the nursing process depend on the accurate and complete collection of data.  Types of Assessment  Initial nursing assessment:  Performed within specified time period  Establishes complete data base  Problem-focused assessment:  Ongoing process integrated with care  Determines status of specific problem  Emergency assessment:  Performed during physiologic or psychological crisis  Identifies life threatening problems  Identifies new or overlooked problem  Time–lapsed assessment:  Occur several months after initial  Compares currant status to baseline  Process of Assessment Collecting data Organizing data Validating Data Documenting Data  Collecting data ♣ Is the process of gathering information about a client health status ♣ It must be systematic and continuous to prevent the omission of significant data ♣ Database: is the all information about client, which include health history, physical assessment and examination, results of diagnostic and laboratory test (Box 11-1) ♣ Data about client should include past history as well as current problem  Subjective Data  Symptoms or covert data  Apparent only to the person affected  Can be described only by person affected  Includes sensations, feelings, values, beliefs, attitudes and of personal health status and life situation  Objective Data  Signs or overt data  Detectable by an observer  Can be measured or tested against an accepted standard  Can be seen, heard, felt or smelled  Obtained through observation or physical examination 4. Which of the following are objective data and which are subjective data. A. Nausea B. Vomiting C. Unsteady gait D. Anxiety E. Bruises on the right arms and face F. Temperature 39  Sources of data  Client  Other individuals  Previous records  Consultations  Diagnostics studies  Relevant literature  Source of Data  Primary source - The client  Secondary sources  All other sources of data such as (family member, spouse, support person, primary care provider, ….etc)  Should be validated if possible  Method of data collection 1. Observing:  Gathering data use the senses  Used to obtain following type of data: Skin color (vision) Body or breath odors (smell) Lung or heart sound (hearing) Skin temperature (touch)  Method of data collection 2. Interviewing:  Planned communication or conversation with a purpose  Used to: Identify problems with mutual concerns Evaluate change Teach Provide support Provide counseling or therapy ☺Approaches to interview  Directive approach: highly structured and elicits specific information.  Nurse establishes purpose  Nurse control the interview  Used to gather or give information when time is limited, e.g in an emergency  Non- directive approach:  Rapport building  Client controls subject matter, purpose and pacing Note: combination of directive and non- directive approaches usually appropriate during the information gathering interview  Types of interview questions: Closed Questions Open ended Questions ♦ Restrictive ♦ Specify broad topic to - Yes\ No discus ♦ Invite longer answers - Factual ♦ Get more information from ♦ Less effort and information from client client ♦ Useful to change topics and ♦ e.g “what medication you take know elicit attitude ♦ e.g “how have you been “ Are you having pain know feeling lately “  Neutral questions  Leading questions  client can answer without  Direct the client’s direction or pressure answers.  open ended  Closed ended  used in nondirective  used in directive interviews. interviews  “How do you feel  “You’re stressed about surgery tomorrow, aren’t  about that?” “What do you?” you think led to the  “You will take your operation?”  medicine, won’t you?” Exercise  What types of these question?  1-How old are you?  2-How did you feel in that situation?  3- What would you like to talk about today?  4-Whwn did you fall?  5-You are stressed about surgery tomorrow, aren't you?  6-You will take your medicine, won’t you?  The interview settings  Time:  Patientfree of pain  Limited interruption  Place:  Private  Comfortable environment  Limited distraction  Seating arrangement:  In hospital  In clinic  In office  Distance:  Comfortable  Language:  Use easily understood terminology  Interpreter or translator  Method of data collection 3. Examining (physical examination):  Systematic data collection method  Uses observation and inspections, auscultation, palpation and percussion Blood pressure (Bp) Pulses Heart and lung sound Skin temperature and moisture Muscle strength Organizing Data  Using written format  Or according to model or frame work  Verifying Data  Double check personal observation  Double check equipments  Check with experts and team member  Recheck outliers  Compare objective and subjective data  Clarify statements  Use references to explain phenomena Documenting Data  Record the client’s data.  Should be accurate,  recorded in factual manner and not interpreted by the nurse (a judgment).