Health Assessment Lecture Notes PDF

Focus of Health Assessment in Nursing HEALTH ​ Physical medical assessment ○​ Focuses primarily on the ASSESSMENT (LEC) client’s physiologic...

Focus of Health Assessment in Nursing HEALTH ​ Physical medical assessment ○​ Focuses primarily on the ASSESSMENT (LEC) client’s physiologic development status ​ Holistic nursing assessment LESSON 1: THE NURSE’S ○​ Collects holistic subjective and objective data to ROLE IN HEALTH determine a client’s overall ASSESSMENT level of functioning in order to make a professional THE NURSING PROCESS clinical judgment ​ ASSESSMENT ○​ Mind, body, and spirit ​ DIAGNOSIS interdependent factors that ​ PLANNING affect each client’s level of ​ IMPLEMENTATION health ​ EVALUATION Framework of Health Assessment in PHASES OF NURSING PROCESS Nursing ​ Assessment: Collecting subjective ​ Many valid nursing assessment and objective data framework methods available ​ Diagnosis: Analyzing subjective and ​ Four basic sections objective data to make a ○​ History of present health professional nursing judgment concern (nursing diagnosis, collaborative ○​ Personal health history problem, or referral) ○​ Family history ​ Planning: Determining outcome ○​ Lifestyle and health practices criteria and developing a plan ​ Implementation: Carrying out the Using Evidence to Promote Health and plan Prevent Disease ​ Evaluation: Assessing whether ​ “Evidence-Based Health Promotion outcome criteria have been met and and Disease Prevention” revising the plan as necessary ​ Healthy People 2030 ​ Many tools available to screen STEP 1: ASSESSMENT clients for potential health risks ​ First and most critical phase ​ USPSTF—risk versus benefit in ​ Collecting subjective and objective screenings data ​ May lead to inadequate or TYPES OF HEALTH ASSESSMENTS inaccurate, incorrect clinical ​ Initial comprehensive assessment judgments if completed incorrectly ○​ Subjective data ​ Is ongoing and continuous ○​ Past health history throughout all phases ○​ Family history ​ More than just gathering information ○​ Lifestyle and health practices  ○​ Objective data ○​ Educate about client’s ○​ Frequency of comprehensive diagnosis and tests assessments depends on performed age, risk factors, health ○​ Reflect on your personal status, health promotion feelings regarding initial practices, lifestyle encounter with client ​ Ongoing or partial assessment ○​ Obtain and organize ○​ Continued data collection materials needed for after comprehensive assessment assessment ○​ Mini overview Collecting Subjective Data ○​ Reassessed any problems ​ Biographical information ○​ Detect any new problems ​ History of present health concern; ​ Focused or problem-oriented physical symptoms related to each assessment body part or system ○​ Does not replace ​ Personal health history comprehensive assessment ​ Family history ○​ Thorough assessment of ​ Health and lifestyle practices particular client problem ​ Review of systems ○​ Does not address areas not related to problem Collecting Objective Data ​ Emergency assessment ​ Physical characteristics ○​ Very rapid assessment in ​ Body functions life-threatening situations ​ Appearance ○​ Goal—provide prompt ​ Behavior treatment ​ Measurements ○​ Only concern is preventing ​ Results of laboratory testing death Validating Assessment Data Steps of Health Assessment ​ Crucial part of assessment ​ Four major steps: ​ Ensures assessment process is not ○​ Collection of subjective data ended before all relevant data have ○​ Collection of objective data been collected ○​ Validation of data ​ Helps prevent documentation of ○​ Documentation of data inaccurate data ​ Steps tend to overlap ​ May perform 2 or 3 steps Documenting Data concurrently ​ Forms the database for entire ​ Preparing for the assessment nursing process ○​ Review client’s record ​ Provides data for all other members ○​ Review client’s status with of health care team other health care team ​ Ensures valid conclusions are made members STEP 2: ANALYZING CUES TO IDENTIFY B.​ Determine outcome criteria and Client CONCERNS develop a plan of care. ​ Identify abnormal cues and C.​ Carry out the plan. supportive cues D.​ Assess whether outcome criteria ​ Cluster cues have been met and revise the ​ Draw inferences and identify and plan as necessary. prioritize client concerns ​ Propose possible collaborative A. Collect subjective and objective data. problems to notify primary care ​ Assessment is collection of provider subjective and objective data. ​ Identify need for referral to primary Planning is determining outcome care provider criteria and developing a plan. ​ Document conclusions Implementation is carrying out the plan. Evaluation is assessing whether Factors Affecting Health Assessment outcome criteria have been met and ​ Culture, family, community will revising the plan as necessary. affect each client, even if only in subtle ways ​ Must be aware of any perceived notions of yourself Question #1 Is the following statement true or false? ​ Physical medical assessment collects holistic subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment. False ​ Holistic nursing assessment collects holistic subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment. Physical medical assessment focuses primarily on the client’s physiologic development status. Question #2 What occurs during the assessment phase of the nursing process? A.​ Collect subjective and objective data. LESSON 2: COLLECTING ​ May reveal special considerations for interviewing client SUBJECTIVE DATA: THE ​ Will guide nurse in obtaining necessary information INTERVIEW AND HEALTH ​ If there is no medical record in the HISTORY system, nurses will need to depend on interviewing skills to elicit all COLLECTING SUBJECTIVE DATA necessary information. ​ Sensations or symptoms ​ Feelings INTRODUCTORY PHASE ​ Perceptions ​ Introduction ​ Desires ​ Explain the purpose of the interview ​ Preferences ​ Discuss the types of questions that ​ Beliefs will be asked ​ Ideas ​ Explain the reason for taking notes ​ Values ​ Assure the client that confidential ​ Personal information information will remain confidential ​ Make sure that the client is INTERVIEWING comfortable and has privacy ​ Requires professional, interpersonal, ​ Develop trust and rapport using interviewing skills verbal and nonverbal skills ​ Two focuses: ○​ Establishing rapport and WORKING PHASE trusting relationship with ​ Biographical data client ​ Reasons for seeking care ○​ Gathering information on ​ History of present health concern developmental, ​ Past health history psychological, physiologic, ​ Family history sociocultural, and spiritual ​ Review of body systems for current status to identify deviations health problems and collaborative ​ Lifestyle and health practices and interventions or strengths developmental level that can be enhanced ​ Listening, observing cues, and using ​ Phases of the interview: critical thinking skills to interpret ○​ Pre Introductory and validate information received ○​ Introductory from the client ○​ Working ​ Collaborating with the client to ○​ Summary and closing identify the client’s problems and goals PRE INTRODUCTORY PHASE ​ Nurse reviews the medical record before meeting the client. ​ Can reveal information that will help assess current needs SUMMARY AND CLOSING PHASE Interacting With an Anxious Client ​ Summarize information obtained ​ Provide the client with simple, during the working phase organized information in a ​ Validate problems and goals with structured format the client ​ Explain who you are and your role ​ Identify and discuss possible plans and purpose to resolve the problem with the client ​ Ask simple, concise questions ​ Make sure to ask if anything else ​ Avoid becoming anxious like the concerns the client and if there are client any further questions ​ Do not hurry ​ Decrease any external stimuli Nonverbal Communication ​ Appearance Interacting With an Angry Client ​ Demeanor ​ Approach the client in a calm, ​ Facial expression reassuring, in-control manner ​ Attitude ​ Allow the client to vent feelings ​ Silence ​ Avoid any arguments with or ​ Listening touching the client ​ Obtain help from other health care Nonverbal Communication to Avoid professionals as needed ​ Excessive or insufficient eye contact ​ Facilitate personal space so that the ​ Distraction and distance client does not feel threatened or ​ Standing cornered ​ Never allow the client to position him Verbal Communication or herself between you and the door ​ Open-ended questions ​ Closed-ended questions Interacting With a Depressed Client ​ Laundry list ​ Express interest in and ​ Rephrasing understanding of the client and ​ Well-placed phrases respond in a neutral manner ​ Inferring ​ Take care not to communicate in an ​ Providing information upbeat, encouraging manner Verbal Communication to Avoid Interacting With a Manipulative Client ​ Biased or leading questions ​ Provide structure and set limits ​ Rushing through the interview ​ Differentiate between manipulation ​ Reading the questions and a reasonable request ​ Obtain an objective opinion from Special Considerations During the other nursing colleagues Interview ​ Gerontologic variations ​ Cultural variations ​ Emotional variations Interacting With a Seductive Client ○​ Allow extra time for ​ Set firm limits on overt sexual client interpreting; determine if behavior and avoid responding to simultaneous or consecutive subtle seductive behaviors mode of interpretation is to ​ Encourage client to use more be used; encourage appropriate methods of coping in interpreter to let you know of relating to others any communication problems ​ If the overt sexuality continues, do ​ During interview not interact without a witness ○​ Introduce self and ​ Report inappropriate behavior to a interpreter; sit looking supervisor directly at client; watch client throughout interview; avoid Discussing Sensitive Issues technical jargon; question ​ Be aware of your own thoughts and client at end for any feelings regarding dying, spirituality, clarification, decisions, or and sexuality recommendations ​ Ask simple questions in a nonjudgmental manner COMPLETE HEALTH HISTORY ​ Allow time for ventilation of client’s ​ Biographical data feelings as needed ​ Reasons for seeking health care ​ If you do not feel comfortable or ​ History of present health concern competent discussing personal, ​ Past health history sensitive topics, you may make ​ Family health history referrals as appropriate ​ Review of systems for current health problems Working With Interpreters ​ Lifestyle and health practices ​ Help interpreter adapt language to ​ Developmental level client’s level of speech and comprehension BIOGRAPHICAL DATA ​ Help interpreter adapt ​ Name communication for clients who ​ Address cannot communicate clearly ​ Phone number ​ Help interpreter be aware of cultural ​ Gender language differences ​ Provider of history (client or other) ​ Help interpreter be aware of other ​ Birth date potential areas of cultural variation ​ Social Security number, medical ​ Help interpreter recognize memory record number, health insurance problems and physical distractions information, or similar identifying may elicit incorrect or insufficient data information ​ Culture, ethnicity, subculture ​ Help interpreter recognize other ○​ Date and place of birth potential barriers to communication ○​ Nationality or ethnicity ​ Prior to interview ○​ Marital status  ○​ Religious or spiritual PQRST Pain Analysis Mnemonic practices ​ P: Provocative/palliative ○​ Primary and secondary ​ Q: Quality languages (spoken, written, ​ R: Radiates and read) ​ S: Severity ​ Educational level ​ T: Timing ​ Occupation; Working status ​ Significant others or support persons Personal Health History (availability) ​ Birth, growth, development ​ Childhood diseases Reason(s) for Seeking Health Care ​ Immunizations ​ “What is your major health problem ​ Allergies or concern at this time?” ​ Medication use: prescription, over ○​ Chief complaint the counter ○​ Client focuses on most ​ Previous health problems significant health concern. ​ Hospitalizations, surgeries, ​ “How do you feel about having to pregnancies, births seek health care?” ​ Previous accidents, injuries ○​ Encourages client to discuss ​ Pain experiences fears or other feelings about ​ Emotional or psychiatric problems having to see health care provider Family Health History History of Present Health Concern ​ Answers to questions provide detailed description of concern ​ Encourage detailed answers to questions ​ Use of various assessment tools assist in collecting necessary data ​ Evaluate client’s insight into problem and plans for managing it ​ Each identified symptom must be described for clear understanding of probable cause and significance REVIEW OF SYSTEMS FOR CURRENT HEALTH PROBLEMS COLDSPA ​ Skin, hair, nails ​ C: Character ​ Head, neck ​ O: Onset ​ Eyes ​ L: Location ​ Ears ​ D: Duration ​ Mouth, throat, nose, sinuses ​ S: Severity ​ Thorax, lungs ​ P: Pattern ​ Breasts, regional lymphatics ​ A: Associated factors/how it affects the client  ​ Heart, neck vessels Question #2 ​ Peripheral vascular Is the following statement true or false? ​ Abdomen ​ The nurse should use closed-ended ​ Genitalia questions to elicit the client’s ​ Anus, rectum, prostate feelings and perceptions. ​ Musculoskeletal ​ Neurologic False ​ The nurse should use open-ended LIFESTYLE AND HEALTH PRACTICES questions to elicit the client’s ​ Description of typical day feelings and perceptions. ​ Nutrition and weight management Closed-ended questions should be ○​ 24-hour dietary intake (foods used to obtain facts and to focus on and fluids) specific information. ○​ Who purchases and prepares meals Question #3 ​ Activity on a typical day and Which sign in a genogram indicates exercise habits and patterns adoption? ​ Sleep and rest a.​ A horizontal dotted line ​ Substance use b.​ A vertical dotted line ​ Self-concept and self-care c.​ An X in a circle responsibilities d.​ An X in a square ​ Social activities b. A vertical dotted line ​ Relationships ​ Rationale: In a genogram, a vertical ​ Values and belief system dotted line may be used to indicate ​ Education and work adoption. A horizontal dotted line is ○​ Type of work, level of job used to indicate the client’s spouse. satisfaction, work stressors An X in a circle indicates a deceased ​ Stress levels and coping strategies female client. An X in a square ​ Environment indicates a deceased male client. ○​ Residency, neighborhood, environmental risks Question #4 Is the following statement true or false? ​ When collecting data about the client’s typical day, inquiring about dietary habits is not necessary. Question #1 False Is the following statement true or false? ​ It is very important to include ​ A client’s feelings and perceptions questions concerning a client’s may be recorded as subjective data. dietary habits when evaluating the client’s concerns. Many chronic True conditions are related to eating and ​ A client’s feelings and perceptions drinking habits and can reveal areas may be recorded as subjective data. that will need to be addressed when planning the nursing care plan. LESSON 3: COLLECTING Preparing the Physical Setting ​ Comfortable, warm temperature OBJECTIVE DATA: ​ Warm blanket if room PHYSICAL EXAM temperature cannot be adjusted ​ Private area free of interruption TECHNIQUES ​ Quiet area with adequate Collecting Objective Data lighting ​ Data directly observed during ​ Firm examination table or bed at interaction with client proper height ​ Information elicited through ​ Bedside table/tray to hold physical examination techniques equipment ​ Nurse must have basic knowledge in three areas: Preparing Oneself ○​ Types and operation of ​ Assess own feelings and anxieties equipment needed before examining client ○​ Preparing self and client ○​ Practice technique on for physical examination “pretend client” with ○​ Properly perform experienced instructor or techniques: inspection, practitioner for feedback palpation, percussion, and ​ Prevent transmission of auscultation infectious agents ○​ Proper hand hygiene Equipment ○​ Wear gloves when ​ Always collect necessary necessary equipment and place where ○​ Properly discard pins or examinations will be performed. other sharp objects, ​ Ensure equipment is working single-client use only properly. ○​ Wear PPEs when ​ Common items: necessary ○​ Gloves and gowns, sphygmomanometer, Standard Precautions for All Client stethoscope, thermometer, Care watch with second hand, ​ Based on risk assessment penlight, ophthalmoscope, ​ Hand hygiene otoscope, rulers or flexible ○​ Alcohol-based hand tape measures, Doppler sanitizer ultrasound, tongue ○​ Soap and water depressors, cotton balls or ​ Gloves gauze pads, tuning forks ○​ Not a substitute for hand hygiene ○​ Change gloves as needed  ​ Skin and nail care ​ Explain procedure being ○​ Prevent dryness from performed. handwashing. ​ Integrate health teaching and ○​ Do not wear artificial nails health promotion during or extensions. examination. ○​ Keep natural nails less ​ Approach the client from the than ¼ in long. right-hand side. ○​ Skin under rings may ​ Explain to the client why position contain high levels of changes are necessary. germs. ​ Assist clients as needed to ​ Respiratory hygiene/cough change positions. etiquette ○​ Use tissues and properly Client Positioning dispose of them. ○​ Perform hand hygiene. ○​ Facilities should provide needed items for staff, clients, and visitors Approaching and Preparing the Client ​ Establish a nurse–client relationship. ​ Explain the procedure and physical assessment, describing the steps of the examination. ​ Respect client’s requests and desires. ​ Explain the importance of the examination. ​ If urine specimen needed, explain why; if not needed, suggest client empty bladder to promote easier examination of the abdomen and genital area. ​ Leave room while client changes clothes, allow client to leave underwear on until genital examination. ​ Begin examination with less intrusive procedures.  deviations from the normal findings? ○​ Is the deviation a normal physical, gerontologic, or cultural finding or abnormal finding? ​ Important questions—(cont.) ○​ Do I need to ask client more questions to validate or obtain more information about my findings? ○​ Do I need to perform physical assessments on other related body systems? ○​ Should I validate my findings with my instructor Examining Older Adults or another health care ​ Some positions may be very practitioner? difficult or impossible for older ○​ Should I refer the client client. and data findings to a ​ Allow rest periods for older adult, primary care provider? if needed. ​ Some older adults process Physical Examination: Inspection information at a slower rate, ​ Uses sense of vision, smell, and explain procedure and integrate hearing teaching in a clear and slow ​ Room at comfortable manner. temperature ​ Good lighting Physical Examination Techniques ​ Look and observe before ​ Must master all four techniques touching ​ Incorrect performance can result ​ Completely expose part being in incorrect objective data examined while draping the rest collection, leading to poor clinical of client as appropriate judgment, which may adversely ​ Note characteristics affect safe client care. ​ Compare appearance of ​ Important questions symmetric body parts or both ○​ Did I inspect, palpate, sides of any individual body part percuss, or auscultate any Physical Examination: Palpation ​ Types: light, moderate, deep, bimanual ​ Palpation consists of using parts of the hand to touch and feel for the following characteristics: ○​ Texture (rough/smooth) ○​ Temperature (warm/cold) ○​ Moisture (dry/wet) ○​ Mobility (fixed/movable/still/vibra ting) ○​ Consistency (soft/hard/fluid filled) ○​ Strength of pulses (strong/weak/thready/bo unding) ​ Palpation consists of using parts of the hand to touch and feel for the following characteristics—(cont.) ○​ Size (small/medium/large) ○​ Shape (well defined/irregular) ○​ Degree of tenderness Physical Examination: Percussion ​ Assessment uses Hand Part Sensitive to ○​ Eliciting pain ○​ Determining location, size, Fingerpads Fine discriminations: and shape pulses, texture, size, consistency, shape, ○​ Determining density crepitus ○​ Detecting abnormal Ulnar or palmar Vibrations, shrills, masses surface fremitus ○​ Eliciting reflexes Dorsal surface Temperature ​ Types ○​ Direct ○​ Blunt ○​ Indirect or mediate ​ Sounds elicited by percussion Physical Examination: Auscultation ○​ Resonance ​ Requires use of stethoscope ○​ Hyperresonance ​ Sounds classified according to: ○​ Tympany ○​ Intensity (loud or soft) ○​ Dullness ○​ Pitch (high or low) ○​ Flatness ○​ Duration (length) ○​ Quality (musical, cracking, raspy) ​ Eliminate distracting or competing noise ​ Expose the body part being auscultated ​ Use diaphragm for high-pitched sounds; bell for low-pitched sounds ​ Place earpieces into outer ear canal ​ Angle binaurals down toward nose ​ Hold diaphragm firmly against body ​ Hold bell lightly against body Correct Use of a Stethoscope ​ Warm diaphragm and bell before use ​ Explain what you are listening to and answer any questions.  ​ Do not apply too much pressure ​ Sitting upright on the side of the when using the bell as it will examination table, the edge of a cause the bell to work like the chair, or a bed is a good position diaphragm. for evaluating the head, neck, ​ Avoid listening through clothes. lungs, chest, back, breasts, axillae, heart, vital signs, and upper extremities. This position is Question #1 also useful because it permits full Is the following statement true or false? expansion of the lungs and allows ​ Good overhead lighting is an the examiner to assess symmetry effective substitute for sunlight of upper body parts. during an assessment. False Question #4 ​ It is best to use sunlight when Depressing the skin surface with the available. However, good dominant hand and using a circular overhead lighting is sufficient. A motion to palpate falls under which portable lamp is helpful for palpation type? illuminating the skin and for A.​ Moderate palpation viewing shadows or contours. B.​ Deep palpation C.​ Bimanual palpation Question #2 D.​ Light palpation Is the following statement true or false? A. Moderate palpation ​ There are times when gloves ​ Moderate palpation involves must be changed between depressing the skin surface 1 to 2 procedures on the same client. cm with the dominant hand and True using a circular motion to feel for ​ Gloves must be changed between easily palpable body organs and tasks and procedures on the masses. same client after contact with material that may contain a high Question #5 concentration of microorganisms. Is the following statement true or false? ​ Percussion that is used to detect Question #3 tenderness over organs by Is the following statement true or false? placing one hand flat on the ​ Sitting upright on the side of the body surface and using the fist of examination table is a useful the other hand to strike the back position while examining the of the hand flat on the body client as it allows full expansion surface is known as direct of the lungs. percussion. True False  ​ Blunt percussion is used to detect tenderness over organs by placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface. Question #6 Is the following statement true or false? ​ When using the stethoscope to auscultate the lungs, the nurse should always apply pressure against the body when using the bell. False ​ The bell of the stethoscope is used to listen to low-pitched sounds and should be held lightly against the body. If too much pressure is applied, the bell will work like the diaphragm and the low-pitched sounds may not be detected. LESSON 4: VALIDATING Identification of Areas for Which Data Are Missing AND DOCUMENTING ​ Once establish an initial database, can identify areas which need more DATA data Validating Data ​ Possibly overlooked certain ​ Verify that subjective and objective questions data are reliable and accurate ​ As examine data in group, realize ​ Steps: additional information needed ○​ Deciding whether data require validation Documenting Data ○​ Determining ways to validate ​ Documentation required by various data state nurse practice acts, ○​ Identifying areas for which accreditation and/or reimbursement data are missing agencies (The TJC, Medicare, ​ Errors cause clinical judgments to be Medicaid), professional made on unreliable data resulting in organizations, institutional agencies diagnostic errors. ​ Health care agencies developed ​ Critical first step of nursing process assessment documentation policies and procedures. Data Requiring Validation ​ Categories of information within ​ Discrepancies or gaps between EHR designed to ensure nurse subjective and objective data gathers pertinent information ​ Discrepancies or gaps in what the ​ REMEMBER, IF IT’S NOT client says at one time versus DOCUMENTED, IT DIDN’T another time HAPPEN! ​ Abnormal and/or inconsistent findings Purpose of Documentation ​ Promote effective communication Methods of Validation among multidisciplinary health team ​ Recheck data through repeat members to facilitate safe and assessment efficient client care ​ Clarify data with client by asking ​ Provides a chronologic source of additional questions client assessment data and a ​ Verify with another health care progressive record of assessment professional findings that outline the client’s ​ Compare objective findings with course of care subjective findings to uncover ​ Ensures that information about the discrepancies client and family is easily accessible to members of the health care team; provides a vehicle for communication; and prevents fragmentation, repetition, and delays in carrying out the plan of care  ​ Establishes a basis for screening or history, family history, validating proposed diagnoses lifestyle, health practices ​ Acts as a source of information to ​ Objective data help diagnose new problems ○​ Physical examination of ​ Offers a basis for determining the client educational needs of the client, ○​ Make notes as perform family, and significant others assessment and document ​ Provides a basis for determining ○​ Avoid documenting with eligibility for care and general nondescriptive or reimbursement nonmeasurable terms ​ Constitutes a permanent legal ○​ Use specific descriptive and record of the care that was or was measurable terms not given to the client Guidelines for Documentation ​ Forms a component of client acuity ​ Keep confidential all documented system or client classification information in the client record. systems ​ Document legibly or print neatly in ​ Provides access to significant nonerasable ink. epidemiologic data for future ​ Use correct grammar and spelling. investigations and research and ​ Avoid wordiness that creates educational endeavors redundancy. ​ Promotes compliance with legal, ​ Use phrases instead of sentences to accreditation, reimbursement, and record data. professional standard requirements ​ Record data findings, not how they were obtained. Information Requiring Documentation ​ Write entries objectively without ​ Every health care agency is unique making premature judgment. in documenting assessments. ​ Two key elements: ​ Record the client’s understanding ○​ Nursing interview/history and perception of problems. ○​ Physical examination: ​ Avoid recording the word “normal” ○​ Subjective data for normal findings. ○​ Objective data ​ Record complete information and details for all client symptoms. ​ Initially document only what client ​ Include additional assessment tells you and what you observe; content when applicable. after adequate data collect, may ​ Support objective data with specific analyze to make valid clinical observations obtained during the judgment physical examination. ​ Subjective data ○​ Biographic data, present health concern(s) and symptom(s), personal health Assessment Forms for Documentation Question #1 ​ Initial assessment form: nursing Is the following question true or false? admission or admission database ​ The nurse should take time to ensure ○​ Open-ended forms, cued or all data agree with the subjective checklist forms, integrated and objective findings. cued checklist, nursing True minimum data set ​ The nurse should always take the ​ Frequent or ongoing assessment time to validate all assessment form: flowcharts that help staff to findings to determine if more data record and retrieve data for frequent are needed to prevent errors in reassessments nursing care and ensure the client ○​ Vital signs, progress notes receives the proper care. ​ Focused or specialty area assessment form: focused on one Question #2 major area of the body for clients Which guideline should the nurse follow for who have a particular problem documentation? A.​ Write “normal” for normal findings. Verbal Communication of Data B.​ Use phrases instead of sentences. ​ Use a standardized method of data C.​ Exclude client’s understanding. communication such as SBAR. D.​ Describe how data were obtained. ​ Communicate face to face with good eye contact. B. Use phrases instead of sentences. ​ Allow time for the receiver to ask ​ When documenting, the nurse should questions. remember to use phrases instead of ​ Provide documentation of the data sentences, avoid using the word you are sharing. “normal” for normal findings, include ​ Validate what the receiver has heard the client’s understanding, and by questioning or asking the receiver record data findings, not how they to summarize your report. were obtained. ​ When reporting over a telephone, ask the receiver to read back what Question #3 the receiver heard you report and Which is a feature of an open-ended document the phone call with time, documentation form? A.​ Consists of check boxes receiver, sender, and information B.​ Promotes use by different caregivers shared. C.​ Promotes rapid documentation D.​ Provides narrative description D. Provides narrative description ​ An open-ended documentation form provides a narrative description of problems. A checklist form uses check boxes and promotes rapid documentation. An integrated cued checklist and a nursing minimum data set promote use by different caregivers. LESSON 5: THINKING ​ Be aware of the influences of the environment. CRITICALLY TO ANALYZE Analyze Data to Make Clinical Judgments: DATA TO MAKE The Second Step of the Nursing Process INFORMED CLINICAL ​ Questions to ask self to evaluate critical thinking skills: JUDGMENTS ○​ Do you reserve your final informed clinical judgment Data Analysis until you have collected most ​ Data analysis: diagnostic or clinical or all of the information? reasoning phase ○​ Do you support your clinical ​ Clinical judgment may be judgment with supporting identification of client concern, data, sound rationale, and collaborative problem, or need for literature? referral. ○​ Do you explore and consider ​ Uses critical thinking to process other alternatives before information, using knowledge, past making a clinical judgment? experiences, intuition, and cognitive ○​ Can you distinguish between abilities to make clinical judgments a fact, opinion, cue, and inference? Making Clinical Judgments Throughout This Book ​ Questions to ask self to evaluate ​ To assess client’s health status, must critical thinking skills—(cont.) analyze subjective and objective ○​ Do you ask your client for data collected more information or ​ Utilize “Making Clinical Judgments” clarification when you do not section in chapters understand? ​ Help develop critical thinking skills ○​ Do you validate your information and judgments Critical Thinking Criteria for Clinical with experts in the field? Judgments ○​ Do you use your past ​ Keep an open mind. knowledge and experiences ​ Use rationale to support opinions or to analyze data? decisions. ○​ Do you try to avoid biases or ​ Reflect on thoughts before reaching preconceived ways of a conclusion. thinking? ​ Use past clinical experiences to build a knowledge base. ​ Questions to ask self to evaluate ​ Acquire and build an adequate critical thinking skills—(cont.) knowledge base from ongoing ○​ Do you try to learn from past education and reading. mistakes in clinical ​ Be aware of the interactions and judgments? influences of others. ○​ Are you open to the fact that you may not always be right? Steps to Make a Clinical Judgment From ​ If cue cluster suggests need for both Assessment Data medical and nursing interventions, ​ Identify abnormal cues and would attempt to identify supportive cues (client strengths). collaborative problems. ​ Cluster cues. ​ Refer clients to other professionals ​ Draw inferences to propose or for assistance and care. hypothesize clinical judgments (opportunities to improve health, risk Step 4: Identify Possible Client Concerns for and actual client ​ If resolution of the situation requires concerns/problems, collaborative primarily nursing interventions, problems, and/or referral to primary would identify possible client care provider). concerns. ​ Identify possible client concerns. ​ Client concern may be actual health ​ Validate the client's concern with the concern, risk for a health concern, or client, family, significant others, opportunity for health promotion and/or health team members. associated with a concern. ​ Document clinical judgments. ○​ Clients may have motivation to increase or improve health Step 1: Identify Abnormal Cues and behaviors and well-being. Supportive Cues (Client Strengths) ○​ May be at risk for concern or ​ Must have knowledge base of problem, may not have anatomy and physiology, problem currently but is psychology, and sociology vulnerable to developing it ​ Knowledge of risk factors ○​ Actual client concern, client is ​ Compared collected assessment currently experiencing stated data with known norms problem ○​ Subjective data ○​ Objective data Step 5: Validate the Client Concern With Others Step 2: Cluster Cues ​ Always validate the client concern ​ Identify strengths and abnormal with the client, family, significant findings for cues that are related. others, or health team members as ​ Cluster both strength cues and needed. abnormal cues. ​ Possible for client to not understand, ​ Consider, again, if additional data including others in the process can are needed. help the client. ​ When client has collaborative Step 3: Draw Inferences to Propose or problem, needs to know what nurse Hypothesize Possible Clinical Judgment is monitoring and who the client ​ Write down inferences (hunches or needs to see for other issues. assumptions) about each cue cluster ​ Provide client with list of available to propose or hypothesize possible resources, when possible, for issues client concerns or collaborative nurse is unable to assist with. problems. ​ Always follow up with client. Step 6: Document Clinical Judgments ​ Common pitfalls ​ Be sure to document all professional ○​ Too many or inadequate observations and data that support data, unreliable or invalid client concern, collaborative data, insufficient number of problems, and referrals. cues available to support ​ Client concerns are often client concerns documented and worded in different ○​ Clustered cues may be formats depending on the agency's unrelated to each other, documentation policy and nurse makes wrong procedure. assumption ​ Actual client concerns ○​ Quickly making clinical ○​ Client concerns (problem) + judgment without associated with + cause or hypothesizing several aggravating factors + as possibilities seen in identified cues ○​ Incorrectly wording the clinical judgment ​ Opportunities to improve health ○​ Overlooking client’s cultural ○​ Opportunity to promote + background when analyzing healthy behavior + data associated with + client’s statement of desire to improve…(health behaviors) ​ Risk for client concerns ○​ Risk for + client concern + associated with + possible cause ​ Collaborative problems and referrals ○​ Risk for Complications (or RC)…(what the problem is) Developing Clinical Judgment Expertise and Avoiding Pitfalls ​ Clinical judgment is considered highly accurate if it is as precise as possible and supported by highly relevant cues. ​ Developing expertise comes with both knowledge and experience. ​ Beginning nurses are still learning. ​ Experts have advantage because they know when exceptions can be applied to rules. ​ Beginning nurses learn how to avoid pitfalls that decrease reliability of cues. Question #1 Is the following statement true or false? ​ It is important for the nurse to carefully consider all cues and ask more questions when more information is needed to make a correct analysis of the situation. True ​ It is important for the nurse to carefully consider all cues, both strength and abnormal cues, and ask more questions to add to the knowledge base in order to make a correct analysis of the situation. Question #2 Is the following statement true or false? ​ It is important for the nurse to first attempt to provide the client the care needed and, if unsuccessful, then refer the client to another health care team member. False ​ There will be times when the client will be experiencing a collaborative health issue and will need referral to a different health team member. The nurse should make the referral and not wait as it can lead to serious complications. Question #3 Is the following statement true or false? ​ Ignoring the client’s cultural background can lead to incorrectly interpreting collected cues from a client. True ​ A common pitfall when interpreting cues is not considering the client’s cultural background. This can lead to misinterpreting the cues and arriving at the wrong analysis of the client’s situation. LESSON 6: ASSESSING Nurse’s Role in Mental Health ​ Nursing assessment MENTAL STATUS ​ Assess and screen for past and present mental health conditions INCLUDING RISK FOR ​ Involves observation, SUBSTANCE ABUSE communication, administering questionnaires or assisting client to Mental Health and Mental Disorders complete self-assessment ​ Mental status refers to level of questionnaires cognitive functioning (thinking, ​ Determine if need for referral to knowledge, problem solving) and another health care professional emotional functioning (feelings, mood, behaviors, stability). Factors Affecting Mental Health ​ Mental health part of one’s total ​ Economic and social factors health ​ Unhealthy lifestyle choices ​ World Health Organization defined ​ Exposure to violence ○​ “Health is a state of complete ​ Personality factors physical, mental, and social ​ Spiritual factors well-being and not merely ​ Cultural factors the absence of disease or ​ Changes or impairments in the infirmity.” structure and function of the ○​ Mental health: “A state of neurologic system well-being in which an ​ Psychosocial developmental level individual realizes his or her and issues own abilities, can cope with the normal stresses of life, Substance Abuse can work productively and is ​ One of most persistent conditions able to make a contribution affecting mental health to his or her community.” ​ Can lead to dependence syndrome ​ Abuse may become priority in life ​ American Psychiatric Association: ​ Marijuana “Any condition characterized by ○​ Legalization cognitive and emotional ○​ Misuse can still lead to disturbances, abnormal behaviors, substance abuse impaired functioning, or any ○​ Different varieties available combination of these.” (joints, bongs, ​ Multiple components contribute to blunts,vaporizers, vape) disorders: environmental, ○​ Concerns for special psychological, genetic, chemical, populations social, or other factors. ​ May also be called: mental illness, psychiatric disorders, psychiatric illness, psychological disorder ​ May affect other body systems  ​ Equipment—(cont.) ○​ SAD PERSONS Suicide Risk Assessment Tool ○​ Primary care posttraumatic stress disorder (PTSD) Screen for DSM-5 (PC-PTSD-5) ○​ St. Louis University Mental Status (SLUMS) Assessment Tool ○​ SBIRT (Screening Brief Intervention and Referral to Treatment) ○​ CAGE questionnaire ○​ The Alcohol Use Disorders Identification Test (AUDIT) Collecting Subjective Data: The Nursing ○​ Clinical Institute Withdrawal Health History Assessment Scale ​ Essential assessment areas for mental health: ​ Level of consciousness and mental ○​ Appearance status ○​ General behavior ○​ Level of consciousness ○​ Cognitive function ○​ Posture, gait, body ○​ Memory movements ○​ Thought processes ○​ Behavior and affect ○​ Use appropriate ○​ Dress and grooming questionnaires or tests ○​ Hygiene ​ Biographical data ○​ Facial expressions ​ History of present health concern ○​ Speech ​ Personal health history ○​ Mood, feelings, and ​ Family history expressions ​ Lifestyle and health practices ○​ Thought processes and perceptions Collecting Objective Data: Physical ​ Cognitive abilities Examination ○​ Orientation ​ Prepare the client ○​ Concentration ​ Equipment: ○​ Recent memory ○​ Pencil and paper ○​ Remote memory ○​ Glasgow Coma Scale ○​ Use of memory to learn new ○​ PHQ-2 information ○​ PHQ-9 ○​ Abstract reasoning ○​ Depression Questionnaire ○​ Judgment ○​ Self-Report Depression ○​ Visual, perceptual, and Questionnaire constructional ability ○​ Columbia Suicide Severity ○​ SLUMS Dementia/Alzheimer Rating Scale (C-SSRS) test examination SLUMS (St. Louis University Mental ​ How often do you have six or more Status) drinks on one occasion? ​ A score of 27 to 30 for clients with a ​ How often during the past year have high school education and a score of you found that you were not able to 25 to 30 for clients with less than a stop drinking once you had started? high school education are ​ How often during the past year have considered normal. you failed to do what was normally ​ For clients with a high school expected from you because of education, a score of 21 to 26 drinking? indicates mild neurocognitive disorder (MNCD); for clients with less ​ How often during the past year have than a high school education, a you needed a first drink in the score of 20 to 24 indicates MNCD. morning to get yourself going after ​ For clients with a high school a heavy drinking session? education, a score of 1 to 20 ​ How often during the past year have indicates dementia; for clients with you had a feeling of guilt or remorse less than a high school education, a after drinking? score of 1 to 19 indicates dementia. ​ How often during the past year have ​ See Assessment Tool 6-3. you been unable to remember what happened the night before because Glasgow Coma Scale you had been drinking? ​ Eye opening response ​ Most appropriate verbal response ​ Have you or someone else been ​ Most integral motor response (arm) injured as a result of your drinking? ​ See Assessment Tool 6-4 ​ Has a relative or friend or a doctor or another health worker been Mini-Cog concerned about your drinking or ​ Instruct the client to remember three suggested you cut down? unrelated words and repeat them back. Depression Questionnaire ​ Instruct the client to draw the face ​ Falling asleep of the clock and note a certain time ​ Sleep during the night by drawing the hands of the clock. ​ Waking up too early ​ Ask the client to repeat three ​ Sleeping too much previously stated words. ​ Feeling sad ​ See Assessment Tool 6-4. ​ Decreased or increased appetite ​ Decreased or increased weight Alcohol Use Disorders Identification Test (within last 2 weeks) (AUDIT) ​ How often do you have a drink ​ Concentration/decision making containing alcohol? ​ Perception of myself ​ How many drinks containing alcohol ​ Thoughts of my own death or suicide do you have on a typical day when ​ General interest you are drinking? ​ Energy level ​ Feeling more sluggish than usual  ​ Feeling restless (agitated, not Clinical Institute Withdrawal Assessment relaxed, fidgety) Scale (CIWA) ​ See Assessment Tool 6-2 ​ Nausea and vomiting ​ Tremor Modified SAD PERSONS Suicide Risk ​ Paroxysmal sweats Assessment ​ Anxiety ​ Sex ​ Agitation ​ Age ​ Tactile disturbances ​ Depression ​ Auditory disturbances ​ Previous attempt ​ Visual disturbances ​ Ethanol abuse ​ Headache ​ Rational thinking loss ​ Orientation and clouded sensorium ​ Social supports lacking ​ Organized plan Affect Variations ​ No spouse ​ Euthymic ​ Sickness ​ Constricted ​ Blunted Warning Signs of Alzheimer Disease ​ Flat ​ Asking the same question over and ​ Labile over again ​ Inappropriate ​ Repeating the same story, word for word, again and again Difference Between Dementia and ​ Forgetting how to cook, or how to Delirium make repairs, or how to play ​ Dementia: Alzheimer disease (AD), cards—activities that were vascular (multi-infarct) dementia previously done with ease and ​ Delirium regularity ​ Various factors: ​ Losing one’s ability to pay bills or ○​ Etiology balance one’s checkbook ○​ Risk factors ○​ Occurrence ​ Getting lost in familiar surroundings, ○​ Age of onset or misplacing household objects ○​ Gender ​ Neglecting to bathe, or wearing the ○​ Course same clothes over and over again, while insisting on having taken a ​ Various factors—(cont.) bath or that one’s clothes are still ​ Duration clean ​ Symptom progress ​ Relying on someone else, such as a ​ Mood spouse, to make decisions or answer ​ Speech/language questions that one previously would ​ Physical signs have handled one’s self ​ Orientation ​ See Assessment Tool 6-6 ​ Memory ​ Personality  ​ Various factors—(cont.) ○​ Stupor ○​ Functional status, ADLs ○​ Coma ○​ Attention span ○​ Psychomotor activity ​ Sources of voice and speech ○​ Sleep–wake cycle problems: ○​ Dysphonia Validating and Documenting Findings ○​ Cerebellar dysarthria ​ Validate data collected. ○​ Dysarthria ○​ Ask additional questions. ○​ Aphasia ○​ Verify data with another ○​ Wernicke aphasia health care professional. ○​ Broca aphasia ○​ Compare objective with subjective findings. ​ Necessary to verify data are reliable and accurate. ​ Document data following health care facility or agency policy. Analysis of Data to Make Clinical Judgments ​ Selected client concerns ○​ Opportunity to improve health ○​ Risk for client concerns ○​ Actual client concerns ​ Selected collaborative problems that need to be monitored and treated by both nursing and primary health care provider ​ Cluster cues to detect potential collaborative problems ​ Monitor ​ Referral to primary care provider for sudden memory loss and extreme confusion. ○​ If you note signs and symptoms that require psychiatric medical diagnosis and treatment, refer to a primary care provider, as necessary. ​ Abnormal levels of consciousness: ○​ Lethargy ○​ Obtunded Question #1 eyes, answering questions, and Is the following statement true or false? falling back to sleep. ​ Mental health issues seldom affect other body systems of the client. Question #4 False Is the following statement true or false? ​ It is not uncommon for a mental ​ Validating all data collected is an illness to affect other body systems. important part of the nursing For example, a depressed client may assessment. stop eating, which will lead to True nutritional deficiencies that will ​ It is very important to validate all affect the entire body and require data collected to help ensure each appropriate intervention. client receives the best nursing care and referral to a primary care Question #2 provider when additional treatment Is the following statement true or false? is needed. ​ Evaluating level of consciousness is part of a mental status examination. True ​ Evaluating level of consciousness is part of a mental status examination. Question #3 Which describes a client who is stuporous? A.​ Awakes to vigorous shake or painful stimulus but returns to unresponsive sleep B.​ Remains unresponsive to all stimuli; eyes stay closed C.​ Opens eyes to loud voice, responds slowly with confusion, seems unaware of environment D.​ Opens eyes, answers questions, and falls back to sleep A. Awakes to vigorous shake or painful stimulus but returns to unresponsive sleep ​ Stuporous is awakening to vigorous shake or painful stimulus but returning to unresponsive sleep. Coma is remaining unresponsive to all stimuli; eyes stay closed. Obtunding is opening eyes to loud voices, responding slowly with confusion, seeming unaware of the environment. Lethargy is opening LESSON 7: ASSESSING ​ If only partially resolved, will experience difficulty in next tasks PSYCHOSOCIAL, ​ Can go back and reclaim lost stages COGNITIVE, AND MORAL ​ Infant: Basic trust versus basic DEVELOPMENT mistrust ​ Toddler: Autonomy versus shame Growth and Development and doubt ​ No single theory embraces all ​ Preschooler: Initiative versus guilt aspects of why humans behave, ​ School ager: Industry versus think, or believe the way they do. inferiority ​ Growth ​ Adolescent: Identity versus role ○​ Addition of new skills or confusion components ​ Young adult: Intimacy versus ​ Development isolation ○​ Refinement, expansion, or ​ Middle adult: Generativity versus improvement of existing skills stagnation or components ​ Older adult: Ego integrity versus despair Erikson Theory of Psychosocial Development Piaget’s Theory of Cognitive Development ​ Involves intrapersonal and ​ Genetic epistemologist interpersonal response to external ​ Focused on how person learns, not events what person learns ​ Societal, cultural, historical factors, ​ Acknowledged interrelationships of and biophysical processes and physical maturity, social interaction, cognitive function influence environmental stimulation, and personality development. experience in general ​ Each stage has a central ​ Major concepts:​ developmental task corresponding ○​ Schema to biophysical maturity and societal ○​ Assimilation expectations. ○​ Accommodation ​ If individual resolves challenge in ○​ Equilibration favor of more positive viewpoint, has achieved positive resolution of ​ Sensorimotor developmental task ○​ Substages: 1, 2, 3, 4, 5, 6 ​ Preoperational ​ Must negotiate healthy balance ○​ Substages: preconceptual, between two concepts to move to intuitive next stage ​ Concrete operational ​ Positive resolution for crisis in one ​ Formal operational stage, necessary for positive resolution in next stage ​ Basic virtues Kohlberg’s Theory of Moral Development ○​ Follow health care facility or ​ Expanded Piaget’s thoughts on agency policy morality ​ Individual morality is a dynamic Assessing Development of Older Adults process that extends over one’s ​ Eriksonian tasks for older adults lifetime. ○​ Embrace realistically ​ Primarily involves affective and reviewing and viewing life cognitive domains in determining ○​ Recognizing errors and poor what is “right” and “wrong” choices ​ Most concerned with “reason” versus ○​ Learning from past “action” experiences what strengths ​ Major concepts: one has ○​ Hard stages ○​ Acknowledging ○​ Justice accomplishments and developing new wisdom ​ Preconventional (premoral) ​ Conventional (maintain external ​ Piaget tasks for older adults expectations of others) ○​ Described the use of formal ​ Postconventional (maintain internal operations as helpful in principles of self—Piaget’s concept anticipating and negotiating of formal operations) the declining of physical and possible cognitive abilities Collecting Subjective Data: The Nursing ○​ Older adults suffer multiple Health History losses and must ​ Biographical data problem-solve about possible ​ History of present health concerns increased dependency, ​ Personal health history decreased choices, and ​ Family history impending death ​ Lifestyle and health practices ○​ Death is seen by the formal ​ General routine screening versus operational thinker as focused specialty assessment universal, inevitable, and irreversible. Assessment Procedure ​ Kohlberg tasks for older adults ​ Assessment of Erikson’s Psychosocial ○​ Professed that those who had Development attained his sixth stage of ​ Assessment of Piaget’s Cognitive personal principles make use Development of self-evaluation, ​ Assessment of Kohlberg’s Moral self-motivation, and Development self-regulation, meeting expectations of their ego Validating and Documenting Findings ideal ​ Validate ○​ Believed that the person ○​ Necessary to verify data are operating at the universal reliable and accurate principle stage is aware of ​ Documentation their “reason for existence” Analysis of Data to Make Valid Clinical Question #1 Judgments Is the following statement true or false? ​ Collect data, identify abnormal ​ Erikson’s developmental task for findings and strengths, cluster cues young adults is intimacy versus ​ Possible client concerns: isolation. ○​ Opportunity to improve True ○​ Risk for Client Concerns ​ Erikson’s developmental task for ○​ Actual Client Concerns young adults is intimacy versus isolation. Question #2 Which assessment tool is used to identify cognitive development? A.​ Freud B.​ Erikson C.​ Piaget D.​ Kohlberg C. Piaget ​ Piaget assesses cognitive development. Freud assesses stages of psychosexual development. Erikson assesses psychosocial development. Kohlberg assesses moral development. Question #3 Is the following statement true or false? ​ When validating the data, it is important for the nurse to cluster the collected cues and ask more questions if the data appear to be incomplete. True ​ Validating the data involves the process of clustering the cues to determine if there are any opportunities to improve, the risk for client concerns, and actual client concerns. If the data appear to be incomplete, then the nurse should ask additional questions so a proper plan can be devised to best assist the client. LESSON 8: ASSESSING ​ At first meeting, observe any significant abnormalities in skin GENERAL HEALTH color, dress, hygiene, posture and gait, physical development, body STATUS AND VITAL build, apparent age, gender SIGNS ​ Generally assess level of consciousness, level of comfort, Structure and Function behavior, body movements, affect, ​ General survey first part of physical facial expression, speech, mental examination acuities ​ Requires all observational skills while interviewing and interacting with Vital Signs client ​ Hands-on physical examination ​ Will lead to clues about health status begins with vital signs. of client ​ Provide data that reflect body ​ Provides nurse with overall systems status impression of client’s whole being ​ Cardiovascular ​ Neurologic ​ General survey includes: ​ Peripheral vascular ○​ Physical development and ​ Respiratory body build ○​ Gender and sexual ​ Temperature development ○​ Core temperature: 36.5°C to ○​ Apparent age as compared 37.7°C (96.0°F-99.9°F orally) to reported age ○​ Methods to use: oral, ○​ Skin condition and color temporal, tympanic, axillary, ○​ Dress and hygiene rectal ○​ Posture and gait ○​ Variations due to: strenuous ○​ Level of consciousness exercise, stress, ovulation ○​ Hypothermia (38.0°C or and affect 100°F) ○​ Facial expression ○​ Speech ​ Pulse ○​ Vital signs ○​ Various sites can be used, most common—radial pulse. Overall Impression of the Client ○​ Normal adult rate: 60 to 100 ​ Tend to remember certain beats/min characteristics ○​ Tachycardia: >100 beats/min ​ Consists of systematic examination ○​ Bradycardia: