NCM 101 - Health Assessment PDF

NCM 101 - HEALTH ASSESSMENT CHAPTER 1: NURSE’S ROLE IN HEALTH ASSESSMENT: COLLECTING AND ANALYZING DATA 2ND SEMESTER AY 2022- 2023 – BSN 1201 SOURCE: PPT TRANSCRIBERS...

NCM 101 - HEALTH ASSESSMENT CHAPTER 1: NURSE’S ROLE IN HEALTH ASSESSMENT: COLLECTING AND ANALYZING DATA 2ND SEMESTER AY 2022- 2023 – BSN 1201 SOURCE: PPT TRANSCRIBERS: John Jayson Agtarap, Ciara Mae Silva, and Princess Ashley Ylagan CHECKER: Vince Gabriel F. Sotejo TOPIC OUTLINE ❖ Draw inferences and identify problems. 1 Assessment: Important for Every Situation ❖ Propose possible nursing diagnoses. 2 Assessment ❖ Check for defining characteristics of those 3 Phases of Nursing Process diagnoses. 4 Analysis Phase of Nursing Process ❖ Confirm or rule out nursing diagnoses. 5 Types of Assessment ❖ Document conclusions. 6 Evolution of the Nurse’s Role in Health Assessment: Past TYPES OF ASSESSMENT 7 Evolution of the Nurse’s Role in Health Assessment within important time periods ❖ Initial Comprehensive Assessment 8 Evolution of the Nurse’s Role in Health Assessment: ▪ Collection of subjective data about the client’s Present perception of health of all body parts or 9 Evolution of the Nurse’s Role in Health Assessment: Future systems, past medical history, family history, 10 Steps of Health Assessment and lifestyle and health practices. 11 Collection of Subjective Data ❖ Ongoing or Partial Assessment ▪ Data collection that occurs after the comprehensive database is established. ASSESSMENT: IMPORTANT FOR EVERY ❖ Focused/Problem-Oriented Assessment SITUATION ▪ Thorough assessment of a particular client problem, which does not cover areas not ❖ Current focus on managed care and internal case related to the problem. management has had a dramatic impact on the ❖ Emergency Assessment assessment role of the nurse. ▪ Very rapid assessment performed in life- ▪ Acute care threatening situations. ▪ Critical care ▪ Ambulatory care ▪ Home health EVOLUTION OF THE NURSE’S ROLE IN HEALTH ASSESSMENT: PAST ASSESSMENT ❖ Physical assessment integral part of nursing ❖ Holistic Nursing Assessment ❖ Nurses relied on natural senses. ▪ Collects holistic subjective and objective data ❖ Palpation to determine a client’s overall level of ❖ Movement of health care from acute care setting to functioning in order to make a professional community care and proliferation of baccalaureate clinical judgment. and graduate education ❖ Physical Medical Assessment ❖ Advanced practice nurses ▪ Focuses primarily on the client’s physiologic development status. EVOLUTION OF THE NURSE’S ROLE IN HEALTH ASSESSMENT WITHIN IMPORTANT TIME PHASES OF NURSING PROCESS PERIODS ❖ Assessment ❖ Late 1800s-Early 1900’s ▪ Collecting subjective and objective data. ❖ 1930-1949 ❖ Diagnosis ❖ 1950-1969 ▪ Analyzing subjective and objective data to make a professional nursing judgment (nursing ❖ 1970-1989 diagnosis, collaborative problem, or referral). ❖ 1990-PRESENT ❖ Planning ▪ Determining outcome criteria and developing a Late 1800s-Early 1900’s plan. ➔ Nurse relied on natural senses alone. ❖ Implementation ▪ Carrying out the plan. ➔ Palpation was used to measure pulse rate and ❖ Evaluation quality and to locate the fundus of the puerperal ▪ Assessing whether outcome criteria have been woman. met and revising the plan as necessary. ➔ Records for independent nursing inspections by palpation and auscultation were noted as early as ANALYSIS PHASE OF NURSING PROCESS 1901 (gastrointestinal palpation, eight cranial nerve function test, and examination of children in school ❖ Identify abnormal data and strengths. systems) ❖ Cluster the data.  1930-1949 Acute Care Nurses ➔ Routine client and home inspections by public health nurses. ➔ Focused assessment with the incorporation of ➔ Frontier Nursing Service and Red Cross lead role in assessment findings to a multidisciplinary team for the case finding, prevention of communicable the development of a comprehensive plan of care. diseases, and routine use of assessment skills in poor inner-city areas. Critical Care Outreach 1950-1969 ➔ Enhanced assessment skills to safely assess critically ill clients outside the structure intensive care ➔ Conduct for pre-employment health stories and environment. physical examinations involving hired nurses from major companies. Ambulatory Care Nurses 1970-1989 ➔ Assessment and screening of clients to determine the need for physician referrals. ➔ Active role of nurses in the provision of primary health services. Home Health Nurses ➔ Expansion of the professional nurse role in conducting health histories, and physical and ➔ Independent nursing diagnosis and referrals for psychological assessments. collaborative problems as needed. ➔ Productivity enhancement of nurses and the health care of clients occurred through in-depth client Public Health Nurses assessments and on-the-spot diagnostic judgments. ➔ Assessment for the need of the communities. ➔ Acute care nurses began to employ the “Primary care” Method of Delivery School and Hospice Nurses ➔ Individualized plans of care were established and nurses became autonomous in making ➔ Monitoring the health and the growth of children for comprehensive initial assessments. school nurses, and the hospice for terminally ill 1990-Present clients and their families. ➔ Use of Advanced Practice Nurses increased in the EVOLUTION OF THE NURSE’S ROLE IN HEALTH community as Nurse Practitioners and as Clinical ASSESSMENT: FUTURE Nurse Specialists within the hospital setting. ➔ Nurses became responsible for assessing and ❖ Rising educational cost validating specific protocols through the use of ❖ Increasing complexity of acute care critical pathways and care maps as referential guides ❖ Growing aging population with complex related to the client progression. comorbidities ➔ Increase in demand for documentation as ❖ Expanding health care needs of single parents justification for health care services provided by ❖ Increasing impact of children and homeless health care practitioners. ❖ Intensifying mental health issues ➔ Increased nurse’s role in the holistic assessment ❖ Expanding health services network solidified due to the proliferation of graduate and ❖ Increasing reimbursement for health promotion and baccalaureate education, and the movement of the preventive care services acute care setting to the community. ❖ Limited number of medical students pursuing ➔ Government and society recognized the need for practice in primary care settings greater cost accountability in the healthcare industry ❖ Aging of the baby boomer generation resulting to the launching of Diagnosis-Related Groups (DRG’s), and for the promotion of health care STEPS OF HEALTH ASSESSMENT (INITIAL) coverage plans, the Health Maintenance ❖ Preparing for the assessment Organizations (HMO’s) and Preferred Provider ▪ Review client’s record Organizations (PPO’s). ▪ Review client’s status with other health care team members EVOLUTION OF THE NURSE’S ROLE IN HEALTH ▪ Educate about client’s diagnosis and tests ASSESSMENT: PRESENT perform. ❖ Acute Care Nurses ❖ Critical Care Outreach Nurses STEPS OF HEALTH ASSESSMENT ❖ Ambulatory Care Nurses ❖ Collection of Subjective Data ❖ Home Health Nurses ❖ Collection of Objective Data ❖ Public Health Nurses ❖ Validation of Assessment Data ❖ School and Hospice Nurses ❖ Documentation of Data  ❖ Analysis of Data ❖ Biographical information ❖ History of present health concern; physical Collection of Subjective Data symptoms related to each body part or system ❖ Personal health history ➔ Elicited and verified only by the client (sensations, ❖ Family history symptoms, feelings, perceptions, desires, beliefs, ❖ Health and lifestyle practices preferences, ideas, values and personal ❖ Review of systems information). COLLECTION OF OBJECTIVE DATA Collection of Objective Data ❖ Physical characteristics ❖ Body functions ➔ Obtained by general observation and physical ❖ Appearance examination techniques (percussion, auscultation, ❖ Behavior palpation, and inspection), observation by other ❖ Measurements health care professionals, family members, and ❖ Results of laboratory testing significant others, and or the client’s medical and health record. Palpation ➔ Assessing the patient by touching with the use of different parts of the hands and with the application and the use of varying degrees of pressure. Auscultation ➔ Assessment through hearing with the use of a stethoscope to identify varied lung, heart, and bowel sounds. Percussion ➔ Tapping the fingers or hands in a quick and sharp manner against parts of the patient's body to locate organ borders, identify organ shape and position, and determine if an organ is solid or filled with fluid or gas. Inspection ➔ Assessment considering vision, smell, and hearing to assess normal conditions in contrast with the deviations. Includes the assessment for color, size, location, movement, texture, symmetry, odors, and sounds as the practitioner assesses related body system. Validation of Assessment Data ➔ Crucial part of the assessment that occurs along with the collection of both subjective and objective data. Documentation of Data ➔ Forms the database for the entire nursing process, providing data for all members of the healthcare team. Analysis of Data ➔ Nursing Diagnosis COLLECTION OF SUBJECTIVE DATA  NCM 101 - HEALTH ASSESSMENT LECTURE 2: COLLECTION OF SUBJECTIVE AND OBJECTIVE DATA 2ND SEMESTER AY 2022- 2023 – BSN 1201 SOURCE: PPT & Recorded Online Session TRANSCRIBERS: Ciara Mae Silva and Princess Ashley Ylagan CHECKER: Vince Gabriel F. Sotejo Client records may be checked and this can reveal TOPIC OUTLINE reasons from the client why he/she seek health care 1 Subjective vs Objective Data assessment and consultation of the past. 2 Subjective Data (Interviewing) It is also necessary to check the medical records before meeting the client upon checking the medical 3 Complete Health History (Subjective Data) records it may reveal information that can assist the 4 Physical Examination (Objective Data) nurse by gathering initial information through the client's biographical information. The nurses may need to rely on interview skills from SUBJECTIVE VS OBJECTIVE DATA the client and significant others (individual’s family) in the absence of an established medical record. SUBJECTIVE DATA OBJECTIVE DATA Key step of the nursing Essential for a compete 1. INTRODUCTORY PHASE health assessment which is nursing assessment. The introduction of the nurse with the client to establish a gathered by means of your trust in a relationship by presenting yourself. interaction to the client a. After the introduction to the client, the nurse: through the interview. ➔ explains the purpose of the interview and why it will be done. ➔ discuss the types of questions that will be Integral part of client Collection requires a great asked. interview to obtain nursing deal of practice to become ➔ explain the reason for taking notes. Remember health history. proficient. to always inform the client and seek for consent. Consist of information Proficiency is needed ➔ assures confidentiality to the client. Always elicited and verified only since “how” the data is assure the client with the confidentiality of the by the client. collected can affect the procedures. Below are the laws that protect the accuracy of the information confidentiality of the patient: elicited. o Health Insurance Portability and Provides the nurse with Includes information Accountability Act (Policies and Laws information that may reveal about the client which the from the United States) a client’s risk for nurse directly observes o Magna Carta for Patients + Republic problems as well as areas during the interaction with Acts + laws in the Philippines of strength for the client. the client or within the clinical setting. b. Nurse ensures the client is comfortable (physically and emotionally) and with privacy. Complete health history is Information is elicited ➔ Initiate and find means to develop trust and done to collect as much as through physical rapport. subjective data about the assessment (examination) client. techniques which includes c. Essential for the development of trust and rapport the percussion, ➔ The development of rapport and trust are auscultation, inspection, established only once the patient senses that and palpation. as a health care provider, your focus alone and concern is on the client's health. The SUBJECTIVE DATA (INTERVIEWING) priority of care is always “client-centered”. Two (2) focuses of the nursing interview process ✓ Developing rapport depends heavily on verbal and 1. Establishing rapport and a trusting relationship. nonverbal communication on the part of the nurse. 2. Gathering information on the client’s developmental, o Negative nonverbal and verbal attitudes may psychological, physiologic, sociocultural, and hinder effective communication during the spiritual statuses. interview. ✓ Below are the positive nonverbal and verbal communication gestures during the effective conduct Three (3) Basic Phases of Client Interview of the interview: 1. Introductory Phase + Preintroductory Phase 2. Working Phase 3. Summary and Closing Phase POSITIVE NONVERBAL COMMUNICATION Preintroductory Phase 1. Appearance The nurse must always appear Preparation for the interview. professional during the conduct of the interview. Review of the medical records before meeting the client. 2. Demeanor The nurse must be in a professional Information may assist the nurse by knowing some of sense. the client’s documented biographical information. Client’s additional information may be revealed if previous data is already present in the system.  3. Facial expression one or two words. The closed-ended questions, typically start with the words It is often overlooked as part of the communication; the when or did. patient's expression shows what you are truly thinking during the interview. Remember that no matter what you 3. Laundry list think about the patient in front of you or if you're having a not so good day, please withhold your expression to any Provides the client with a list of words to choose in neutral manner in a friendly professional manner. describing the symptoms or can also be in terms of conditions or feelings. This approach helps the healthcare Displaying the neutral expression does not mean that you provider to obtain specific responses and at the same time, are lacking of expression, it just means that you are using it lessens the possibility of the client providing certain the right expression during the interview. expected answers. The use of the laundry list is beneficial in terms as well of the use of the repetition of choices and Take note that smiling when the client is in the verge of it depends on the necessity for the use of choices. emotion, it can result that the client might think that you do not care at all with his/her health condition. The nurse or 4. Rephrasing healthcare provider must be cautious with the display of facial expression. Provides an effective way to communicate during the interview. This particular verbal communication helps the 4. Attitude nurse to clarify the information which the patient initiated, and it is also beneficial to the healthcare provider since it This is one of the most important verbal skills to be enables the nurse and the client to reflect on what was enhanced as they have their practitioner, and this must be previously mentioned. enhanced in a nonjudgmental attitude and it's secure that the client is being informed on certain restrictions as well. 5. Well-placed phrases 5. Silence The health care provider encourages the verbalization or the expression of the currently experienced symptom or The presence of silence as part of a number by feeling and even the beliefs of the client. The use of well- communication is also included and the periodic silence placed phrases by the usage of “yes” and “I agree”, coming during the conducted interview allows the health care from the healthcare provider, it encourages the client to provider and the client to reflect and to organize their continue with the flow of thoughts or the flow of expression. thoughts during the interview, during the question, and the answer portion of the interview. And this facilitates an 6. Inferring accurate reporting and data collection. This technique in the positive verbal communication helps 6. Listening to elicit the most accurate data possible which the client may provide during the exchange of the question and This is particularly included as part of nonverbal responses between the client and the nurse. The thing to communication since the healthcare provider needs to be cautioned for is that the health care provider must be maintain not only good eye contact, not only the appropriate careful not to lead the patient to answers that are not patient expression and other positive gestures but the exactly true. Information from what the client tells the dependency as well to the client that you're an effective healthcare provider and what the nurse observes in the listener and that you take concentration during the client's attitude or behavior may elicit more possible data or responses being provided by your client. it can also verify the existing data being presented during the assessment. This nonverbal communication is an important skill to be enhanced and developed to assure that there will be 7. Providing information completion and validity of data coming subjectively from your client because it is essential with the establishment of The health care provider must ensure to answer all inquiries trust between nurse and client. or questions from the client as thoroughly as possible. And once the healthcare provider does not exactly know how to respond or is not unsure about the response, explain to the POSITIVE VERBAL COMMUNICATION client that particularly you will arrange or you will find out the certain response from that inquiry. The good thing about 1. Open-ended questions providing the information, the more the patient knows about their current health status, the more likely possibility that These are used to secure or to elicit the client's feelings and they are to become cooperative or even equal participants perceptions. These types of questions are important since in taking care of health promotion. they require more than one word response coming from the patient and therefore this encourages description. Moreover, asking open-ended questions may also help to ✓ VERBAL AND NONVERBAL reveal significant data about the present client's health COMMUNICATION TO AVOID: status of the patient. NONVERBAL COMMUNICATION Additionally, these questions typically begin with the words how or what. 1. Excessive or insufficient eye contact 2. Closed-ended questions This is related to the development of trust since insufficient eye contact shows that the interviewer or the health care Used to obtain facts and to focus on specific information provider has less interest during the interview and indicates gathering. On this question, the client may respond with excessive eye contact, some clients will feel uncomfortable with too much eye contact. The best thing to do is to secure 3. SUMMARY AND CLOSING PHASE a moderate amount of eye contact during the interview a. Nurse summarizes information obtained from the 2. Distraction and distance working phase and validates problems and goals with the client. b. Identification and discussion of possible plans to Remember to avoid being occupied with something else resolve the problems with the client. while you are doing the interview process specifically if you c. Checking for other concerns or further questions from started asking questions during the interview since this the clients. particular behavior makes the client believe that the interview may not be important to you. It lessens the development of trust and rapport. SPECIAL CONSIDERATIONS IN COLLECTING SUBJECTIVE DATA DURING INTERVIEW 3. Standing 1. Gerontologic Find professional means to This is another gesture to avoid during the interview. Once Variations in encourage client cooperation you are standing during the conduct of the interview, the Communication and involvement. client may perceive you as superior making the patient feel inferior. 2. Cultural o Take caution with the Variations in construction of sentences Communication during the interview. ✓ Aside from the nonverbal communication gestures to be o Check the necessity for avoided there are also verbal communication gestures. cultural brokers. o Consider health care VERBAL COMMUNICATION system or setting dominant from the client’s cultural background. 1. Biased or leading questions This causes the patient to provide answers, which is not 3. Emotional Aging results to decline of true at all. And it is related on how the healthcare provider Variations in responses. constructs the questions, leading the client to assume that Communication you want the patient to answer in a certain manner as if you are giving cues or directing the patient to respond on a COMPLETE HEALTH HISTORY certain way. (SUBJECTIVE DATA) 2. Rushing through the interview Serves as groundwork for nursing problem identification. Aside from it making the client uncomfortable because the Provides assistance for areas of client strength. interview is being rushed, it will result into the collection of Answers the question regarding the aim of physical incomplete answers to the questions asked during the assessment. conduct of the collection of the subjective assessment in Checking for lifestyle and current health status. the interview Provides specific cues associated to present health problems. 3. Reading the questions Conduct commences first with informing the client about the purpose of complete health history. This will lead to the patient's deflection of attention and it Begins with an explanation to the client on why the results in an impersonal interview process and in information is being requested. connection with this, this results as well in the client Lays the groundwork for identifying nursing specifically, those clients who feel unease during the problems and provides a focus for physical interview and instead of opening up to the health care examination. provider, this will lead into the failures of communication as Provides information that assists the examiner in well. identifying areas of strength and limitation in the individual’s lifestyle and current health status. Provides the examiner with specific cues to health 2. WORKING PHASE problems most apparent to the client. a. Nurse elicits the clients’ comments about: Maybe modified or shortened as necessary. o major biographic data o reasons for seeking health care o history of present concern EIGHT SECTIONS OF HEALTH HISTORY o past health history o family history 1. Biographic Data o review of body systems (for current health problems) Information that identifies the client such as: o life style and health practices ✓ Name o developmental level ✓ Birthdate b. Nurse listens, observes cues, and uses critical ✓ Place of birth thinking skills to interpret and validate the ✓ Gender information. ✓ Address c. Nurse and client collaborate to identify client’s ✓ Race/Ethnic background problems and goals. ✓ Marital Status ✓ Religious/Spiritual practices  ✓ Educational level ✓ Occupation ✓ Phone number 6. Review of body systems for current health ✓ Medical record number problems ✓ Social security number ✓ Source of information (client or significant other) Each body system is addresses and the client is ✓ Support persons asked specific questions to draw out current health problems from the recent past that may 2. Reasons for seeking health care. still affect the client or that are recurring. Includes only the client’s subjective Major health problem or concern: Reasons for information and not the examiner’s seeking healthcare observation when considering areas for Fears and past experience: Feelings about rendering care. seeking healthcare Questions about problems and signs or symptoms of disorders should be asked in terms 3. History of present health concern that the client understands. Findings on the part of the nurse may be Takes into account aspects of the health recorded in standard medical terminology. problem and asks questions whose answers can provide a detailed description of the 7. Lifestyle and health practices profile concern. Starts with encouraging the client to explain the Deals with the client’s human responses which includes the health problem or symptom in a many details as following: possible. a) Description of typical day Focuses under history of present health b) Nutrition and weight management concern: c) Activity level and exercise ✓ Onset d) Sleep and rest ✓ Progression e) Substance use ✓ Duration of the problem f) Self-concept and self-care responsibilities ✓ Signs and symptoms g) Social activities ✓ Related problem h) Relationships ✓ Client perception of what causes the i) Values and belief system problem j) Educational and work k) Stress levels and coping styles COLD SPA: Mnemonic designed to help the health care l) Environment provider to explore signs and symptoms and or health concerns. 8. Developmental level CHARACTER Use of questions to assess the client’s developmental level ONSET during the stages of young adult (intimacy vs. isolation), LOCATION middle scent (generativity vs. stagnation) and older adult DURATION (ego integrity vs. despair). SEVERITY PATTERN ASSOCIATED FACTORS PHYSICAL EXAMINATION (OBJECTIVE DATA) 4. Personal Health History Information about the client that the nurse directly observes during the interaction with the client. Focuses on questions related to the client’s personal Information elicited through physical assessment history form the earliest beginnings to the present. (examination) techniques. Checking or asking for the following: Proficiency in physical assessment skills requires a ✓ Childhood illnesses and immunization. background in three (3) basic areas. ✓ Recall past surgeries and accidents. 1. Types and operation of equipment needed for ✓ Describing any prolonged episodes of pain or pain the particular examination. patterns. 2. Preparation of the setting, oneself, and the ✓ Allergies and use of prescription and over-the- client for the physical assessment. counter medications. 3. Performance of the four assessment techniques. 5. Family Health History Use of the genogram to illustrate and organize the client’s family history. Provides records of the diseases and health conditions in the client’s family. Checking should include as many genetic relatives as the client many recalls: ✓ Age of parents (living and deceased) ✓ Parent’s illnesses and longevity ✓ Grandparents’ illnesses and longevity. ✓ Children’s ages and illnesses and longevity and handicaps.  3 BASIC AREAS IN PHYSICAL ASSESSEMENT SKILLS 1. Preparing Equipment Prior to the client assessment, to promote a sense of organization and to prevent the nurse from leaving the client to search for equipment, the examiner must collect. the necessary equipment and place it in the examination area. 2. Preparing physical setting, oneself, and client Preparing Physical Setting Nurse must ensure that the examination setting meets the following conditions: a. Comfortable, warm room temperature b. Private area free of interruptions from others c. Quiet area free of distractions Preparing Oneself For beginning examiners, it is best to assess your own feelings and anxieties before examining the client. Achieve self-confidence in performing a physical assessment by practicing related techniques. Ensure the prevention of transmission of infectious agents. Preparing Client Establish the nurse-client relationship during the interview before the physical assessment. Respect the client’s desires and requests related to physical examination. Begin the examination with less intrusive procedures such as measuring the vital signs, height, and weight. Approach the client from the right-hand side of the examination table or bed since most examination techniques are performed with the examiner’s right hand. 3. Physical Examination Techniques a. Inspection b. Palpation c. Percussion d. Auscultation After performing each of the four basic techniques, examiners should ask themselves questions that will facilitate analysis of the data and determine areas for which more data may be needed.  NCM 101 - HEALTH ASSESSMENT LECTURE 2: COLD SPA 2ND SEMESTER AY 2022- 2023 – BSN 1201 SOURCE: PPT TRANSCRIBERS: Ciara Mae Silva and Princess Ashley Ylagan CHECKER: Vince Gabriel F. Sotejo establish at the very moment your client and patient TOPIC OUTLINE relationship and to establish rapport. We need to identify some examples of questions relating to 1 Cold Spa the characteristics belonging to the conditions to identify the 2 Character signs and symptoms of your clients. 3 Onset 4 Location CHARACTER 5 Duration Deals with asking your client with questions that will 6 Severity allow or will enable the nurse to gather descriptions of 7 Pattern the actual signs and symptoms experienced by the client. 8 Associated Factors An example question for this is asking the client on the situation that this is being applied in the patient experiencing back pain. So, to distinguish character, COLD SPA you may ask: Mnemonic designed to help the health care provider to ➔ “What does the pain feel like?” explore signs and symptoms and or health concerns. ➔ and allow the client to express the feeling related to To gather and to verify the data elicited and verified by your the pain or if not only regarding the pain in general clients and that is through the collection of the subjective when you are dealing with the character as part of data. the cold spa, it will also allow you as the healthcare provider to distinguish the perception of the client ➔ Client answers to the questions provide the nurse with with regards to the senses in terms of smell, the information about the client’s problems and how it taste, the sound or even the appearance of the sign affects lifestyle and activities of daily living (ADL) manifested or experience of the client. ➔ Helps the nurse to evaluate the client’s insight into the problem and the client’s plan for managing. Cold spa belongs to the eight sections of health ONSET history. Asking the client when the pain started to determine the Under the sections of the health history within is the start of the pain. history of the present health concern of your client, Actual time wherein the patient experiences the signs wherein the cold spa belongs to this assessment for and symptoms. signs and symptoms manifested and experienced by Ex: When did the pain started? the client is Mnemonic, which is designed to assist the nurse in exploring for the signs and symptoms, LOCATION including the additional health concerns of your client. Specifying for site of the affected area or structure of the body of the client. (CHARACTER-ONSET-LOCATION-DURATION-SEVERITY- You may ask the patient to point out the specific location PATTERN-ASSOCIATED FACTORS) of the pain. Ex: Is the pain radiating towards other body structure? Through this technique, cold spa helps the healthcare Where does it hurt the most? provider to evaluate the client's insight regarding his/her experience, concern, or his/her condition and with the DURATION inclusion of the possible formulation of plans for nursing Checking for length of period and recurrence. management. Ex: How long does the pain last? Does it come and go With the conduct of this technique, this involves asking or is it constant? specific and concise questions so that the nurse may be able to gather responses in relation to the mnemonics, the characteristics which are mentioned in terms of a character, SEVERITY onset location, and the rest of the characteristics belonging Verification of intensity to your cold spa. You may use the pain scaling chart to assess how bad Through these particular specific questions or guides to be the pain is. (if the complaint is related to pain) asked to the patient, the client will answer the questions and Ex: How bad is it? How does these particular symptoms this will provide the healthcare provider with the bother you in your ADL? information needed to identify the client's problem during the data collection and the nurse will be also capable PATTERN in distinguishing the effects of the signs and the symptoms Asking for related factors affecting the chief complaint affecting the lifestyle as well as the activities of the daily of the client. living of your client. Ex: What makes the condition worst? Are there factors which aggravates the condition? Are there any The activities of the daily living of the client which is treatments that you have tried previously that have abbreviated as our ADL. These are the skills that are been effective in decreasing the pain? required by your patient to manage the basic physical needs such as grooming, dressing, even the conduct for proper hygiene, eating in terms of nutrition, the associated practices ASSOCIATED FACTORS which nourish or provide nourishment for your client, Checking for other symptoms that occur along the ambulatory mechanism, the movement of your client and complaint. even the excretion of waste materials. You may ask how the related factors affects the client This COLD SPA requires the establishment of effective with regards to their ADL. communication between the nurse and the client. That's Ex: What do you think cause the symptom or the signs why it is vital during the initial contact with your client to experienced?  NCM 101 - HEALTH ASSESSMENT LECTURE 2: COLLECTING SUBJECTIVE AND OBJECTIVE DATA 2ND SEMESTER AY 2022- 2023 – BSN 1201 SOURCE: PPT TRANSCRIBER: Rod H. Maranan CHECKER: Vince Gabriel F. Sotejo TOPIC OUTLINE WHEN INTERACTING WITH A SEDUCTIVE CLIENT 1 Isolation and Precaution Guidelines Set firm limits on overt sexual client behavior. 2 National Sleep Foundation Client Education Avoid responding to subtle seductive behaviors. 3 Research-Based Approaches to Promote Sleep Encourage client to use more appropriate methods of 4 Interacting With Clients with Various Emotional States coping in relating to others. 5 SBAR (Situation, Background, Assessment, and WHEN INTERACTING WITH A MANIPULATIVE CLIENT Recommendation) Provide structure and set limits. Differentiate between manipulation and reasonable ISOLATION AND PRECAUTION GUIDELINES request. SAFE INJECTION PRACTICES If unsure for the presence of manipulation obtain an Do not administer medications from single-dose vials or objective opinion from members of the team. ampules to multiple patients (or combine leftover WHEN INTERACTING WITH A DEPRESSED CLIENT contents for later use). Express interest in the understanding of the client and Use single-dose vials for parenteral medications respond in a neutral manner. whenever possible. Do not try to communicate in an upbeat, encouraging Use aseptic technique to avoid contamination of sterile manner. injection equipment. WHEN INTERACTING WITH AN ANGRY CLIENT DO NOT ADMINISTER medications from a syringe to Approach the client in a calm, reassuring, and in-control multiple patients, even of the needle or cannula on the manner. syringe is changed. Allow the client to ventilate feelings. Needles, cannulas, and syringes are sterile, single-use If the client is out of control, do not argue with or touch items and should not be reused for another patient. the client. Used fluid infusion and administration sets for one Avoid arguing and facilitate personal space so that the patient only and dispose appropriately after use. client does not feel threatened or cornered. WHEN INTERACTING WITH AN ANXIOUS CLIENT NATIONAL SLEEP FOUNDATION CLIENT Provide clients with simple, organized information in a EDUCATION structured format. Establish a regular sleep schedule. Explain who you are, along with your role and purpose. Establish a regular, relaxing bedtime routine. Ask simple, concise questions. Create a sleep conducive environment. Avoid becoming anxious like the client. Sleep on a comfortable mattress and pillow. Do not hurry, and decrease any external stimuli. Use bedroom only for sleep and sex. Finish eating at least 2 to 3 hours before regular SBAR (SITUATION, BACKGROUND, bedtime. ASSESSMENT, AND RECOMMENDATION) Exercise regularly and complete exercises hours before SITUATION State concisely why you bedtime. need to communicate the Avoid caffeine, nicotine and alcohol. client. Use over the counter sleep medications for a short BACKGROUND Describe events that led up period of time. to the current situation. Seek medical advice for prescription sleep medications. ASSESSMENT State the subjective and Seek cognitive behavioral therapies for long term- objective data gathered benefits. RECOMMENDATION Suggest what you believe needs to be done for the RESEARCH-BASED APPROACHES TO client based on your assessment findings. PROMOTE SLEEP Use of herbs, aromatherapy and herbal supplements ADDITIONAL INFORMATION FROM IN-PERSON Related dietary supplements. SESSION Music therapy, acupuncture and relaxation Nosocomial infection – hospital acquired infection techniques. Community acquired infection – prevalent and existing disease in the community; development of INTERACTING WITH CLIENTS WITH VARIOUS disease acquired to exposure in community. EMOTIONAL STATES Passive carrier – no signs and symptoms WHEN DISCUSSING SENSITIVE ISSUES (SEXUALITY, Immunocompromised client – includes old age client, DYING, AND SPIRITUALITY) adults, those who are undergoing extensive therapies, Be aware of your own thoughts and feelings regarding HIV/AIDS, chemotherapy, pregnant client, and school- dying, spirituality and sexuality. aged children (not fully developed immune system) Ask simple questions in a nonjudgmental manner. Vaccination – promotes safety of both health care Allow time for ventilation of the client’s feelings as provider and other people. needed. PPA/Equipment – must be sterile Ask referrals as appropriate.  Fluids from patient – considered as contaminant (ex: blood) Client positioning – part of the preparation of the client; must be done in a short period of time Communication with the client must be gentle and therapeutic Sitting position – position if the client has problems with stability, balance, and walking; consider other position if the patient has an existing problem with the lower back; applicable for getting vital signs and checking the upper extremities. Knee-chest Position – rectal area; when conducting a procedure with this position, ensure the sterility of the equipments Standing Position – cephalocaudal approach, frontal structures Prone Position – not applicable to patients with respiratory problems Sim’s Position – examination of rectal area; suppository medications Dorsal Recumbent Position - not applicable with patients having problems in their abdomen Supine Position – for clients who undergo surgery/anesthesia, do not put pillow under client, lie only on bed because it will cause spinal headache “Preserve the dignity of client” Draping – prevents the exposure of unnecessary parts of the body that is not related to the examination and assessment; promotes client’s comfort Syringe – 1 needle = 1 patient Warm bath – promotes relaxation of the muscle To prevent spasm, consider taking soothing warm bath before sleep Prescriptions from the doctors – high dosage of medicines like sleep inducing medicine Cognitive and Behavior therapy – sleeping patterns, PTSD, psychological problems Herbalist (herbolaryo) – recognized by DOH Aromatherapy – diffuser (diffusers not applicable for pregnant client) Acupuncture – Chinese medicine; done in certain points of body; promotes circulation Relaxation technique – breathing exercise before sleep; yoga Short, Concise, Informative – assurance given to patient who is anxious During different emotional states, it is important to get recognized by patients as a healthcare provider Client depression – mood indicator down; everything is down Manipulative client – bargain for their gain  NCM 101 - HEALTH ASSESSMENT LECTURE 2: COLLECTION OF SUBJECTIVE AND OBJECTIVE DATA 2ND SEMESTER AY 2022- 2023 – BSN 1201 SOURCE: PPT TRANSCRIBER: John Jayson Agtarap CHECKER: Vince Gabriel F. Sotejo TOPIC OUTLINE LIFESTYLE AND HEALTH PRACTICES 1 Magna Carta of Patient's Rights and Obligations Act → Description of Typical Day of 2017 → Nutrition and Weight Management 2 Rights of the Patients 3 Related Laws → Activity Level and Exercise 4 Life Style and Health Practices → Sleep and Rest 5 Positioning the Client → Substance Use 6 Isolation and Precaution Guidelines → Social Activities → Relationships MAGNA CARTA OF PATIENT'S RIGHTS → Values and Belief System AND OBLIGATIONS ACT OF 2017 → Education and Work ➔ It is a declared policy of the State to ensure and → Stress Levels and Coping Styles protect the rights of patients to decent, humane, and → Environment quality health care. Description of Typical Day ➔ Further, the State shall adopt an integrated and ➔ Elicit an overview of how the client see his usual comprehensive approach to health and development pattern of daily activity. which shall endeavor to make essential goods, ➔ Questions asked should be vague enough to allow health, and other social services available to the the client to provide of orientation from which the day people at affordable costs. is viewed. ➔ The State shall likewise endeavor to provide free ➔ Start with awakening in the morning and continue medical care to the pauper. until bedtime. ➔ Additional specific questions may be asked to draw out more details if client gives minimal information. RIGHTS OF THE PATIENT ➔ Encourage the client to discuss a usual day. Right to Appropriate Medical Care and Humane Treatment. Right to Informed Consent. Nutrition and Weight Management ➔ Ask the client to recall what consists of an average Right to Privacy and Confidentiality. 24-hour intake with emphasis on what foods are Right to Information. eaten and in what amounts. The Right to Choose Health Care Provider and ➔ Identify who buys and prepares the food as well as Facility. when where meals are eaten. Right to Self-Determination. ➔ Clients’ food intake should be compared with the Right to Religious Belief. guidelines illustrated in the food pyramid. Right to Medical Records. ➔ Check for the patient’s bowel and bladder habits. Right to Leave. Refuse Participation in Medical Research. Activity Level and Exercise Right to Correspondence and to Receive Visitors. ➔ Inquiry for regular exercise. Right to Express Grievances. ➔ Distinguish between activity is done when working Right to be Informed of His Rights and Obligations as (stressful and fatiguing) and exercise (designed to a Patient. reduce stress and strengthen individual. ➔ Explain regular exercise reduces the risk of heart disease, and stress, strengthens the heart and lungs, RELATED LAWS and manages weight. Republic Act Law on reporting of Communicable Diseases. ➔ Distinguish the client’s answers with a recommended 3573 Majority age is 18 years old. exercise regimen (20 to 30 minutes / three times a Republic Act 6809 week). Republic Act Magna Carta of Disabled Persons. 7277 Sleep and Rest Republic Act Special protection of children ➔ Questions should focus on specific sleep patterns 7610 against abuse, exploitation and such as how the many hours a night the person discrimination act. sleeps. Republic Act Hospital Doctors to treat ➔ Compare the client’s answers with the normal sleep 8344 emergency cases referred for requirement for adults (5 to 8 hours a night). treatment. ➔ Identify interruptions, problems with sleeping, rituals, and concerns about sleeping habits. ➔ Sleep requirements vary depending on age, health, and stress levels.  Degree of Sleepiness Scale Rating Education and Work Feeling active, vital, alert, or 1 ➔ Identifies areas of stress and satisfaction in the wide awake. client’s life. Functioning at high levels, but 2 ➔ Discussing this area will help the client feel good not at peak; able to about what he has accomplished and promote his concentrate. sense of life satisfaction. Awake, but relaxed; responsive 3 ➔ Questions should bring out data about the kind and but not fully alert. amount of education the client has. Somewhat foggy, let down. 4 ➔ Similar questions should be asked about work Foggy; losing interest in 5 history. remaining awake; slowed down. Stress Levels and Coping Styles Sleepy, woozy, fighting sleep; 6 ➔ Questions that address what events cause stress for prefer to lie down. the client. No longer fighting sleep, sleep 7 ➔ Identification of how the client responds to stress. onset soon; having dream-like ➔ To avoid denial responses, nondirective questions or thoughts. observations regarding previous information Asleep X provided by the client may be an easy way to establish discussion. ▪ Score rating of 1 = ideal ➔ Allow the healthcare provider to find out what relieves ▪ Score grater than 3 = serious sleep debt and stress and whether the behaviors/activities can be require more sleep. construed as adaptive or maladaptive. ▪ 9AM and 9PM = daily peak times for alertness ▪ 3PM = usual lowest point for alertness Environment ➔ For the assessment of health hazards unique to the Substance Use client’s living situation and lifestyle. ➔ Information gathered about substance use provides ➔ Look for physical, chemical, and psychological the nurse with information concerning lifestyle and situations that may put the client at risk. the client’s self-care ability. ➔ Hazards may be controllable and uncontrollable and ➔ Identify how often the client takes the substance and may be found in the client’s home, work, inquire for the amounts consumed. neighborhood and or recreational environment. ➔ Substances are known to affect the client’s health and may cause loss of function or impaired senses. ➔ Substances increase the client’s risk for diseases. LIFESTYLE AND HEALTH PRACTICES Social Activities → Sitting Position ➔ Helps the nurse to identify outlets the client has for → Suping Position → Dorsal Recumbent Position support and relaxation (involvement in the community → Sims Position beyond family and work information to determine the → Standing Position client’s current level of social development). → Prone Position → Knee-Chest Position Relationships → Lithotomy Position ➔ Ask for the composition of the family into which they were born and about past and current relationships Sitting Position with these family members. ➔ Good for head, neck, lungs, chest, ➔ Assess problems and potential support from the back, breast, axillae, heart, vital client’s family of origin. signs, and upper extremities. ➔ Similar information may be sought about the client’s ➔ Permits full expansion of the lungs. current family. ➔ Assessment for symmetry of upper ➔ In absence of family by blood or marriage, gather body parts. information from significant others that may constitute ➔ Supine position with the head the client’s “family”. elevated as an alternative position. Values and Belief System Supine Position ➔ Discuss the client’s philosophical, religious, and ➔ Small pillows may be spiritual beliefs. placed under the head ➔ Some clients may not be comfortable with discussing to promote client values or beliefs. comfort. ➔ Data gathered may help to identify important ➔ Position allows the abdominal muscles to relax. problems or strengths. ➔ Provides easy access to peripheral pulse sites. ➔ Head of the bed may need to be raised for the difficulty of breathing.  Dorsal Recumbent Position Standing Position ➔ Client lies down with knees ➔ Client stands still in a normal, comfortable, bent and legs separated and resting posture. and the feet flat on the bed. ➔ Allows examiner to asses posture and gait. ➔ Abdomen should not be ➔ Used for examining the male genitalia. assessed due to contraction in the position. ➔ May be more comfortable than the supine position for clients with pain in the back or abdomen. ISOLATION AND PRECAUTION GUIDELINES Sims’ Position Safe Injections Practices ➔ Client lies on the right or ➔ Do not administer medications from single-dose vials left side with the lower or ampules to multiple patients ( or combine leftover arm placed behind the contents for later use). body and the upper arm ➔ Use single-dose vials for parenteral medications flexed at the shoulder and elbow. whenever possible. ➔ Lower leg slightly flexed at the knee while the upper ➔ Use aseptic technique to avoid contamination of leg is flexed at a sharper angle and pulled forward. sterile injection equipment. ➔ Used for assessing rectal and vaginal areas. ➔ DO NOT ADMINISTER medications from a syringe ➔ Client may need some assistance in the position. to multiple patients, even of the needle or cannula on ➔ Elderly and clients with joint problems may have the syringe is changed. difficulty in assuming and maintaining the position. ➔ Needles, cannulas, and syringes are sterile, single- use items and should not be reused for another Knee-Chest Position patient. ➔ Client kneels on the ➔ Used fluid infusion and administration sets for one examination table with the patient only anddispose appropriately after use. weight of the supported by the chest and knees. ➔ 90-degree angle should exist between the body and hips. ( head turned to side, arms placed above the head ) ➔ Useful in examining the rectum. ➔ Maybe embarrassing and uncomfortable for the client. ➔ Client should be kept in the position for as limited time as possible. ➔ Elderly and clients with respiratory and cardiac problems may be unable to tolerate the position. Prone Position ➔ Client lies down on the abdomen with the head to the side. ➔ Used primarily to assess hip joint and back of the client. ➔ Clients with respiratory problems cannot tolerate the position. Lithotomy Position ➔ Client lies on the back with the hips at the edge of the examination table (feet supported by stirrups). ➔ Used for examination of the female genitalia, reproductive tracts, and rectum. ➔ As an exposed position, the client may feel embarrassed, and is best to keep the client well- draped during the examination. ➔ Perform examination as quickly as possible.  NCM 101 - HEALTH ASSESSMENT LECTURE 3: VALIDATING & DOCUMENTING DATA 2ND SEMESTER AY 2022- 2023 – BSN 1201 SOURCE: PPT & Online Recorded Session TRANSCRIBERS: DENZEL RAE B. ARIDA & PRINCESS JOY DE CHAVEZ CHECKER: VINCE GABRIEL F. SOTEJO TOPIC OUTLINE PURPOSES OF VALIDATION 1 Validation VS Documentation Confirming or verifying that the subjective and 2 Purposes of Validation objective data are reliable and accurate. 3 Purposes of Documentation Failure to validate data may result in premature 4 Information Requiring Documentation closure of the assessment or collection of inaccurate 5 Guidelines for Documentation data. 6 Assessment Forms Used for Documentation 7 Features of Initial Assessment Documentation Forms 8 Verbal Documentation of Data PURPOSE OF DOCUMENTATION 9 Data Requiring Validation Provides the healthcare team with a database that 10 Methods of Validation becomes the foundation for the care of the client. 11 Identification of Areas with Missing Data Identifies health problems, formulate nursing diagnoses and plan immediate and ongoing interventions. VALIDATION VS DOCUMENTATION Promote effective communication among the VALIDATION OF DATA DOCUMENTATION OF multidisciplinary health team members for the DATA facilitation of safe and efficient client care. Verifies the assessment Act of recording the client Eliminate repetition of similar data collected by other data gathered from the assessment findings. health team members. client. Promotion of effective communication among the Determination of which data Starts with the nurse multidisciplinary health team and elimination of requires validation. knowing the purpose of repetition of similar data collection. documentation. Identification of areas which Following the require further assessment understanding for INFORMATION REQUIRING data. documentation purposes, DOCUMENTATION requires which information 2 Key Elements for inclusion in every Documentation: to document. Nursing History (Subjective Data) Use of implementing Familiarization for Physical Assessment (Objective Data) techniques to validate. documentation forms used within their respective health care agency is essential as part of the GUIDELINES FOR DOCUMENTATION process. Keep confidential all documented information in the Nurses need to know how to verbally communicate client record. assessment findings in a clear and concise manner to other Document legibly or print in nonerasable ink. healthcare providers. Use correct grammar and spelling. Avoid wordiness that creates redundancy. Take note: Not all the data that you will be able to gather Use phrases instead of sentences to record data. during the interaction with your client needs verification. Record data findings. Write entries objectively without making premature IMPORTANCE OF DATA DOCUMENTATION AND judgments or diagnoses. DATA VALIDATION Record the client’s understanding and perception of Documentation serves as the justification for your problems. Avoid recording the word normal for normal findings. nursing or your possible nursing actions, including to Record complete information and details for all client that is your interventions and by means of the data symptoms and experiences. documentation, it will ensure that the gathered data Include additional assessment content when may be objective or subjective. applicable. Validation ensures that the assessment conducted is Support objective data with specific observations complete by means of double checking and verifying obtained during the physical examination. data to be confirmed in terms of accuracy and to ensure that the data by means of validation that the data is factual and accurate in terms of the conduct ASSESSMENT FORMS USED FOR of the nursing process. DOCUMENTATION Initial Assessment Form Frequent/Ongoing Assessment Form STEPS OF VALIDATION Focused/Specialty Area Assessment Form 1. Decide whether the data require validation. 2. Determine ways to validate the data. 3. Identify areas for which data are missing.  FEATURES OF INITIAL ASSESSMENT DOCUMENTATION FORMS Open-Ended Forms (Traditional Form) Cued or Checklist Forms Integrated Cued Checklist Nursing Minimum Data Set VERBAL DOCUMENTATION OF DATA Use the standardized method of data communication Communicate face-to-face with good eye contact. Allow time for the receiver to ask questions. Provide documentation of the data you are sharing Validate what the receiver has heard by questioning or asking him or her to summarize your report. Additional notes from Online Recorded Session: Validated data must comply standardized method of data communication as well, which is part of SBAR. Verbally communicating and relaying the data, there must be a face-to-face communication with maintaining good eye contact and during the interaction as well, the healthcare provider must allow time for the receiver to ask questions, provide documentation of the data that you are sharing in written or in electronic file format. Allow time for the receiver to ask questions. Provide documentation of the data you are sharing. During the verbal documentation as well, the healthcare provider must validate what the receiver on the other end of the communication has heard by asking or by securing questions which will allow for the sum up of the report or the documented data. DATA REQUIRING VALIDATION Discrepancies or gaps between the subjective and objective data. Discrepancies or gaps between what the client says at one time versus another time. Findings that are highly abnormal and or inconsistent with other findings. METHODS OF VALIDATION Recheck own data through a repeat assessment. Clarify data with the client by asking for additional examples. Verify the data with another healthcare professional. Compare objective findings with subjective findings to uncover discrepancies. IDENTIFICATION OF AREAS WITH MISSING DATA Additional information is needed as data are examined in a group format. Certain questions are overlooked and requires area identification. Identification of areas requiring more data occurs once initial data base are finally established.  NCM 101 - HEALTH ASSESSMENT LECTURE 4: CRITICAL THINKING TO ANALYZE DATA AND MAKING INFORMED NURSING JUDGEMENTS 2ND SEMESTER AY 2022- 2023 – BSN 1201 SOURCE: PPT TRANSCRIBERS: GRACE GARCIA & DANIELLE BAY CHECKER: VINCE GABRIEL F. SOTEJO TOPIC OUTLINE 1 IDENTIFY ABNORMAL DATA AND 1 Analysis of Data STRENGTHS 2 Essential Elements of Critical Thinking Remember to analyze both subjective and objective 3 Diagnostic Reasoning Process data when identifying strengths and abnormal 4 7 Key Steps for the Analysis of Data findings. 5 Developing Diagnostic Reasoning Expertise and Nurses should compare collected assessment data Avoiding Pitfalls with findings in reliable charts and reference resources that provide standards and values for physical and psychological norms. ANALYSIS OF DATA Nurses should have a basic knowledge of risk factors Second step of the nursing process, is the purpose and for clients. the end result of the assessment. Risk factors are based on client data such as gender, Often called “Diagnostic Phase” because the purpose age, ethnic background, and occupation. of the phase is the identification of nursing diagnoses Nurses need to have access to both the data supplied and collaborative problems. by the client and the known risk factors for specific Diagnostic reasoning is the thought process required diseases or disorders. for data analysis, a form of critical thinking. Identifying abnormal findings and client strengths In diagnostic reasoning, it is important to develop the requires the nurse to have and use a knowledge base characteristics of critical thinking in order to analyze as of: accurately as possible. o Sociology Special part of the analysis of data includes an o Psychology assessment of each body part or system since the o Physiology and Anatomy analysis of data is closely linked to assessment. Novice nurses may learn to increase diagnostic These areas along with the use of reference materials, and accuracy by becoming aware of and avoiding the attention to risk factors help to identify strengths, risks, pitfalls of diagnosing. and abnormal findings. Developing expertise in formulating nursing diagnoses requires background and expertise as professionals on Identified strengths are used in formulating health the field of practice. promotion diagnoses. Identified potential weaknesses are used in formulating risk diagnoses. ESSENTIAL ELEMENTS OF CRITICAL Abnormal findings are used in formulating actual THINKING nursing diagnoses. Keep an open mind. 2 CLUSTER DATA Use a rationale to support opinions or decisions. Nurses look at the identified abnormal findings and Reflect on thoughts before reaching conclusions. strengths for cues that are related. Use past clinical expertise to build knowledge. Clustering of both abnormal and strengths cues. Acquire an adequate knowledge base that continues Use of particular nursing framework as a guide when to build. possible. Be aware of the interactions of others. Nurses may find certain cues are pointing toward a Be aware of the environment. problem but more data are needed to support the determination of the identified problem during the DIAGNOSTIC REASONING PROCESS clustering of data. Make sure you have accurately performed the steps 3 DRAW INFERENCES of the assessment phase of the nursing process since Requires the nurse to write down hunches about all the related information coming from it will have a each cue cluster. profound effect on the conclusions you reach in the You would write down what you think these data are analysis step of the nursing process. saying and the nurse needs to determine whether is Once you are confident with the accuracy and something that the nurse can treat independently. sufficiency of the assessment phase, proceed with The inference the nurse may draw from a cue cluster the analysis of data through the seven (7) key steps. suggests the need for both medical and nursing Regardless of how the information is organized, interventions to resolve the problem leading to diagnostic reasoning always consists of the key generating collaborative problems. steps. Collaborative problems are defined as “certain physiological complications that nurses monitor to detect their onset or changes in status. Nurses manage collaborative problems using 7 KEY STEPS FOR THE ANALYSIS OF DATA physician-prescribed and nursing-prescribed 1 Identify abnormal data and strengths. interventions to minimize the complications of events. 2 Cluster data. Collaborative problems are equivalent in importance 3 Draw inferences. to nursing diagnoses but represent the 4 Propose possible nursing diagnosis. interdependent or collaborative role of nursing. 5 Check for the presence of defining characteristics. Referral of identified problems for which the nurse 6 Confirm or rule out nursing diagnoses. cannot prescribe definitive treatment occurs at 7 Document conclusions. drawing of inferences. DEFINITION Referring can be defined as connecting clients with other professionals and resources.  Referral is the identification or suspicion of a medical 7 DOCUMENT CONCLUSIONS problem based on the subjective and objective data Ensure to document all of your professional collected. judgments and the data that support those Referral process differs per health care setting, judgments. sometimes the nurse makes a direct referral or it may Nursing diagnoses are often documented and be the policy to notify the nurse practitioner or worded in different formats. physician, who if unable to intervene, will make the referral. 4 PROPOSE POSSIBLE NURSING DIAGNOSIS DEVELOPING DIAGNOSTIC REASONING If the resolution of the situation requires primarily EXPERTSE AND AVOIDING PITFALLS nursing interventions, the nurse may hypothesize and Pitfalls decrease the reliability of cues and decrease generate possible nursing diagnoses. diagnostic accuracy. Nursing diagnoses may be wellness or health promotion, risk diagnosis, actual nursing TWO (2) SETS OF PITFALLS diagnosis, and syndrome diagnosis. A Those which occur during the assessment pha