NCM 101 Health Assessment PDF

NCM 101 HEALTH ASSESSMENT Nursing Process Definition Nursing process- is a critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness (American Nurses Associa...

NCM 101 HEALTH ASSESSMENT Nursing Process Definition Nursing process- is a critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness (American Nurses Association, 2010).  Nursing process is a systematic method of providing care to clients. The nursing process is a systematic method of planning and providing individualized nursing care. Purposes of Nursing Process 1. To identify a client’s health status and actual or potential health care problems or needs. 2. To establish plans to meet the identified needs. 3. To deliver specific nursing interventions to meet those needs. Characteristics of Nursing Process ✓Cyclic- repeated process ✓Dynamic in nature ✓Client centeredness ✓Focus on problem solving and decision making ✓Interpersonal and collaborative style ✓Universal applicability ✓Use of critical thinking and clinical reasoning. Components of nursing process It involves assessment(data collection),nursing diagnosis, planning, implementation, and evaluation. 1. ASSESSMENT  ASSESSMENT is the systematic and continuous collection, organization, validation, and documentation of data (information) Types of assessment 1. Initial nursing assessment: Performed within specified time after admission. To establish a complete database for problem identification. Eg: Nursing admission assessment 2. Problem-focused assessment: To determine the status of a specific problem identified in an earlier assessment. Eg: hourly checking of vital signs of fever patient  Generally are repeated frequently or on a schedule basis to determine trends in a client’s condition and responses to the interventions. Example: ✓ Post Operative Rating of Pain ✓ Neurologic Status Monitoring of a patient with head injury (Glasgow Coma Scale) 3. Emergency assessment: During emergency situation to identify any life threatening situation. E.g.: Rapid assessment of an individual’s airway, breathing status, and circulation during a cardiac arrest. 4. Time-lapsed reassessment: Several months after initial assessment. To compare the client’s current health status with the data previously obtained. Collection of data Data collection is the process of gathering information about a client’s health status. It includes the health history, physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.  Types of Data 1. Subjective data- also referred to as symptoms or covert data, are clear only to the person affected and can be described only by that person. Itching, pain, and feelings of worry are examples of subjective data. 2. Objective data- also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard.  They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination. For example, a discoloration of the skin or a blood pressure reading is objective data.  EXERCISE STOP, THINK AND RESPOND MEG CLASSIFY THE FOLLOWING DATA 1. Patient Charles rates his headache as 6 in the pain scale. 2. Frederick has a GSW on his right lateral oblique. 3. Reni states that he slept very well and feels rested. 4. Kristoffer’s mom states that his son feels a throbbing headache. 5. Tachycardic- an abnormally rapid heart rate  ORGANIZE THE FOLLOWING DATA  Example: ✓ Lassitude ✓ Its boring ✓ Temperature- 38.8 degrees Celsius ✓ Thick sputum ✓ “My stomach is painful” ✓ Distended abdomen ✓ I want to vomit ✓ I am nauseated ✓ Dry and hard stool passed with difficulty ✓ Weak cough MEG Subjective and Objective Data Subjective data Objective data ✓ Its boring ✓ Lassitude ✓ “My stomach ✓ 38.8 degrees Celsius is painful” ✓ Thick sputum ✓ I want to ✓ Distended vomit abdomen ✓ I am ✓ Dry and hard nauseated stool passed with difficulty ✓ Weak cough  Sources of Data 1. Primary : It is the direct source of information. The client is the primary source of data. Example: The patient verbalizes,“ My stomach is excruciating”. 2. Secondary: It is the indirect source of information. All sources other than the client are considered secondary sources. Family members, health professionals, records and reports, laboratory and diagnostic results are secondary sources. Example: 1. The mother claims that her daughter's abdomen is bigger than yesterday. 2. Abdominal girth increased at 2cm from yesterday’s 27 cm. 3. Presence of a 23mm mass at the distal third of the fallopian tube per ultrasound. Methods of data collection The methods used to collect data are observation, interview and examination. 1. Observation : It is gathering data by using the senses. Vision, Smell and Hearing are used. 2.Interview : An interview is a planned communication or a conversation with a purpose. There are two approaches to interviewing: 1. The directive interview is highly structured and directly ask the questions. And the nurse controls the interview. 2. A nondirective interview, or rapport building interview and the nurse allows the client to control the interview. STAGES OF AN INTERVIEW An interview has three major stages: 1. The opening or introduction 2. The body or development 3. The closing 3. Examination : The physical examination is a systematic data collection method to detect health problems. ✓ To conduct the examination, the nurse uses techniques of inspection, palpation, percussion and auscultation. Organization Of Data The nurse uses a format that organizes the assessment data systematically. This is often referred to as nursing health history or nursing assessment form. Example in S and O data. Validation Of Data The information gathered during the assessment is “double-checked” or verified to confirm that it is accurate and complete. Documentation Of Data To complete the assessment phase, the nurse records client data. Accurate documentation is essential and should include all data collected about the client’s health status. 2. DIAGNOSIS  Diagnosis is the second phase of the nursing process. In this phase, nurses use critical thinking skills to interpret assessment data to identify client problems. North American Nursing Diagnosis Association (NANDA) define or refine nursing diagnosis.  The official NANDA definition of a nursing diagnosis is: “a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.” Components of a NANDA Nursing Diagnosis 1. The problem statement describes the a client’s health problem. 2. The etiology component of a nursing diagnosis identifies causes of the health problem. 3. Defining characteristics are the cluster of signs and symptoms that indicate the presence of health problem. Formulating Diagnostic Statements The basic three-part nursing diagnosis statement are the PES format and includes the following: 1. Problem (P): statement of the client’s health problem (NANDA label) Name of the health-related issue or problem as identified in the NANDA list. Formulating Diagnostic Statements 2. Etiology (E): causes of the health problem “ related to” ( should not be a medical diagnosis) 3. Signs and symptoms (S): defining characteristics manifested by the client. Evidence (“as manifested by” or “as evidenced by”) Ex. Acute pain related to abdominal surgery as evidenced by patient discomfort and pain scale. Pain scale and Acute Surgery of discomfort of Pain abdomen patient Disturbed sleep pattern related to excessive intake of coffee as manifested by difficulty in falling asleep, feeling tired during the day and irritability with others. Status of the Nursing Diagnosis The status of nursing diagnosis are actual, health promotion and risk. 1. An actual diagnosis is a client problem that is present at the time of the nursing assessment. A problem that currently exists Ex. Impaired Physical Mobility related to pain as evidenced by limited range of motion, reluctance to move 2. POSSIBLE DIAGNOSIS- A problem may be present, but requires more data collection to rule out or confirm its existence Possible Parent Role Conflict related to impending divorce. 3. A risk nursing diagnosis is a clinical judgment that a problem does not d exist, but the presence of risk factors indicates that a problem may develop if adequate care is not given. A problem the client is uniquely at risk for developing Risk for Deficient Fluid Volume related to persistent vomiting 4. Syndrome Diagnosis Cluster of problems predicted to be present because of an event or situation (Carpenito, 2004) ▪ Rape Trauma Syndrome and Disuse Syndrome 5. WELLNESS DIAGNOSIS A health-related problem at which a healthy person obtains nursing assistance to maintain or perform at a higher level. Potential for Enhanced Breastfeeding  NANDA If the problem does not fit into any of the NANDA- approved categories, the nurse can use his /her own terminology when stating the ND  Differentiating Nursing Diagnosis from Medical Diagnosis Nursing diagnosis Medical Nursing diagnosis Medical diagnosis diagnosis A nursing diagnosis is a A medical diagnosis is made by a statement of nursing judgment physician. that made by nurse, by their education, experience, and expertise, are licensed to treat. Nursing diagnoses describe the Medical diagnoses refer to human response to an illness or a disease processes. health problem. Nursing diagnoses may change A client’s medical diagnosis as the client’s responses change. remains the same for as long as the disease is present. Nursing diagnosis Medical diagnosis Ineffective breathing Asthma pattern Activity intolerance Cerebrovascular accident Acute pain Appendicitis Disturbed body image Amputation  EXERCISE STOP, THINK AND RESPOND Which DS is written correctly based on the data and information below? The client eats only bites of the food served. She has lost 15 lbs. in the last 3 weeks and is now weighing 130 lbs. She has been experiencing acute vomiting after eating for the last three weeks and is physically weak.  Which of the following ND statement is written correctly based on the data and the information? 1. Risk for Imbalanced Nutrition: Less than Body Requirements related to vomiting 2. Imbalanced Nutrition: Less than Body Requirements related to inadequate intake of food secondary to vomiting as manifested by caloric intake below daily requirements, recent weight loss of 15 lbs, and current weakness. 3. Weight Loss related to vomiting as evidenced by reduced intake of food. 4. Possible Malnutrition due to inadequate consumption of nutrients. 3. PLANNING  It is the process of prioritizing nursing diagnoses, identifying measurable goals or outcomes, selecting appropriate interventions and documenting the plan of care.  Planning involves decision making and problem solving. It is the process of formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client’s health problems.  Whenever possible, the nurse consults the patient in developing and revising for his/her care. Planning measures what the client and nurse will use to accomplish identified goals Involves critical thinking TYPES OF PLANNING 1. Initial Planning : Planning which is done after the initial assessment. 2. Ongoing Planning : It is a continuous planning. 3. Discharge Planning : Planning for needs after discharge  Planning Process 1. Setting priorities- The nurse begin planning by deciding which nursing diagnosis requires attention first, which second, and so on. Nurses frequently use Maslow’s hierarchy of needs when setting priorities. Henderson’s 14 Fundamental Needs  It is important to determine which problems require the most immediate attention. Prioritization is done in more than one way. 2. Establishing client goals/desired outcomes After establishing priorities, the nurse set goals for each nursing diagnosis. Goals may be short term or long term. GOAL Expected or desired outcome. It helps the health team determine if the nursing care has been appropriate in the management of the nursing diagnosis.  EXAMPLE GOAL ✓ The patient will be well hydrated by January 21,2019. OUTCOME ✓ The patient will have adequate hydration as evidenced by an oral intake between 2,000-3,000 mL/24 hours and a urine output of +/- 500 mL of the intake amount by January 21,2019.  Kinds of Goals 1. SHORT TERM GOALS ✓outcomes achievable in a few days to 1 week ✓most in acute care settings Characteristics of Short Term Goals: 1. Specific 2. Measurable 3. Accompanied by a target date 4. Realistic 5. Time- bound 6. Client-centered COMPONENTS OF A SHORT - TERM GOAL NURSING DIAGNOSTIC STATEMENT ▪ Constipation related to decreased fluid intake, lack of dietary fiber, and lack of exercise as manifested by no bowel movement for the past 3 days, abdominal cramping, and straining to pass stool. COMPONENTS OF A SHORT - TERM GOAL client- centered SHORT-TERM GOAL identifies measurable Within the criteria that rotation, the reflects the client will problem portion of the diagnostic have a bowel statement movement COMPONENTS OF A SHORT - TERM GOAL Within the ✓ identifies a rotation, target date for (specify date) Achievement within a realistic time frame 2. LONG TERM GOAL ✓takes weeks or months to accomplish for clients having chronic health problems Example: ✓Client with a cerebrovascular accident will return to full or partial function to the paralyzed limb. Communicating the Plan of Care ✓Clients need consistency and continuity of care to achieve goals. ✓The nurse shares the plan of care with the nursing team members, the client, and the client’s family. 4. IMPLEMENTATION  Implementation consists of doing and documenting the activities. “The process of implementation includes; Implementing the nursing interventions and documenting nursing activities” The process of implementation includes; Implementing the nursing interventions Documenting nursing activities Nursing interventions A nursing intervention is any treatment, that a nurse performs to improve patient’ s health.  Selecting Nursing Interventions Nursing interventions planned should be; a. Safe b. Within the legal scope of nursing practice c. Compatible with medical orders TYPES OF NURSING INTERVENTIONS 1. Independent interventions are those activities that nurses are licensed to initiate on the basis of their knowledge and skills. 2. Dependent interventions are activities carried out under the orders or supervision of a licensed physician. 3. Collaborative interventions are actions the nurse carries out in collaboration with other health team members. Writing Individualized Nursing Interventions After choosing the appropriate nursing interventions, the nurse writes them on the care plan. Nursing care plan is a written or computerized information about the client’s care. 5. EVALUATION Evaluation is a planned, ongoing, purposeful activity in which the nurse determines (a)The client’s progress toward achievement of goals/outcomes and (b)The effectiveness of the nursing care plan.  “REVIEW” 1. The phase of the nursing process that involves collecting, validating, organizing, and recording data about the patient’s health status is; A. Assessment B. Diagnosing C. Implementation D. Evaluation 2. On reviewing the patient’s care plan, the notation: High risk for falls related to weakness, disorientation and faulty judgment, is an example of; A.Outcome Identification B.Nursing Diagnosis C.Assessment D.Evaluation 3. Which of the following nursing diagnosis is correct? A.High risk for falls related to absence of side rails. B.Ineffective airway clearance related to myasthenia gravis. C.Disturbed sleep pattern related to persistent coughing during the night. D.Self-care deficit and anxiety related to severe joint pain 4. Which of the following statements is incorrect when establishing priorities during outcome identification phase of the nursing process? A.Airway should be given highest priority. B.Physiologic needs are given priority over psychosocial needs. C.Give priority to patients with unstable condition. D.Patients for discharge and who require health teachings should be attended to first, before the other patients. 5. Which of the following is the primary source of data? A.The patient’s chart B.The patient C.The patient’s physician D.The patient’s nearest relative