Kozier & Erb's Fundamentals of Nursing, Chapter 11 - Assessing PDF

KOZIER & ERB’S Fundamentals of NURSING NINTH EDITION Concepts, Process, and Practice CHAPTER 11...

KOZIER & ERB’S Fundamentals of NURSING NINTH EDITION Concepts, Process, and Practice CHAPTER 11 Assessing Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Nursing Process Overview Nursing process – is a systematic, rational method of planning and providing individualized nursing care. Its purposes are: To identify a client’s health status and actual or potential health care problems or needs To establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs. *****The client may be an individual, a family, a community, or a group. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Five or six phases – Assessing ---data collection – Diagnosing--- problems – Identifying outcomes (sometimes included) – Planning--- writing a plan (determining a goal) – Implementing---- enforcement the plan (action---intervention) – Evaluating---- judge ( good \bad) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved. Figure 11-1 (continued) The nursing process in action. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved. Although nurses may use different terms to describe the phases (or steps) of the nursing process, the activities of the nurse using the process are similar.  For example, implementing may be called implementation, intervention, or intervening. The phases of the nursing process are not separate entities but overlapping, continuing subprocesses. Each phase of the nursing process affects the others; they are closely interrelated Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Characteristics of the Nursing Process Cyclic and dynamic rather than static(‫)ﺳﺎﻛن‬ Client centered Problem-solving and systems theory Decision making Interpersonal and collaborative Universal applicability Critical thinking skills Please read page 156 Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Please see table 11-1 \ page 158 Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Assessing It is the systematic and continuous collection, organization, validation, and documentation of data. Assessing is a continuous process Assessments vary according to their purpose, timing, time available, and client status. 4 types of assessment( table 11-3 page 161 ) – Initial nursing assessment – Problem-focused assessment – Emergency assessment – Time-lapsed reassessment Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Types of Assessments Initial – Performed within a specified time period – Establishes complete database Problem-Focused – Ongoing process integrated with care – Determines status of a specific problem Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Types of Assessments (cont'd) Emergency – Performed during physiologic or psychologic crises – Identifies life-threatening problems – Identifies new or overlooked problems Time-lapsed – Occurs several months after initial – Compares current status to baseline Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Collecting Data Gathering information about client’s health status Must be systematic and continuous Includes past history and current problem Subjective or objective Primary or secondary source Establishes database , it includes the nursing health history physical assessment, results of laboratory and diagnostic tests. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Types of data Subjective data ===== symptoms Objective data ==== signs Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Subjective Data Symptoms or covert (secret ) data Apparent only to person affected Can be described only by person affected Includes sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situations Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Objective Data Signs or overt( clear ) data Detectable by an observer Can be measured or tested against an accepted standard Can be seen, heard, felt, or smelled Obtained through observation or physical examination Include such data as blood pressure. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Sources of Data Primary source The client is the best source of data The nurse is often much closer to the client than other members of the health care team Secondary sources Family members or other support persons, other health professionals, records and reports, laboratory and diagnostic analyses, and relevant literature are secondary or indirect sources Should be validated, if possible Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Please read box 11-1 page 162 Please read table 11-4 page 163 Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Methods of Data Collection The principal methods used to collect data are:  Observing: occurs whenever the nurse is in contact with the client or support persons. Interviewing : is used mainly while taking the nursing health history Examining: is the major method used in the physical health assessment. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  In reality, the nurse uses all three methods simultaneously when assessing clients Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Methods of Data Collection 1. Observing (table 11-5 page 164) – Gathering data using the senses Observing has two aspects: (a) noticing the data and (b) selecting, organizing, and interpreting the data. – Used to obtain following types of data:  Skin color (vision)  Body or breath odors (smell)  Lung or heart sounds (hearing)  Skin temperature (touch) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved. Methods of Data Collection (cont’d) 2. Interviewing Interview - planned communication or a conversation with a purpose to get or give information, identify problems, evaluate change, teach, provide support, or provide counseling or therapy. – Used to:  Get or give information  Identify problems of mutual concern  Evaluate change  Teach  Provide support  Provide counseling or therapy Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Approaches to interview There are two approaches to interviewing: Directive  nondirective Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Directive Approach to Interviewing Highly structured and elicits specific information. Nurse establishes purpose Nurse controls the interview The client responds to questions ,have limited opportunity to ask questions or discuss. Used to gather and give information when time is limited, e.g., in an emergency Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Nondirective Approach to Interviewing Rapport-building (Rapport is an understanding between two or more people). Client controls the purpose, subject matter, and pacing Combination of directive and nondirective approaches is usually appropriate during information-gathering interview Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Types of Interview Questions Closed questions – Restrictive  Yes/no  Factual – Less effort and information from client – “What medications did you take?” – “Are you having pain now?” Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Types of Interview Questions (cont’d) Open-ended questions – Specify broad topic to discuss – Invite longer answers – Get more information from client – Useful to change topics and elicit attitudes – “How did you feel in that situation? Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Neutral question the client can answer without direction or pressure from the nurse.  open ended used in nondirective interviews. Examples are “How do you feel about that?” “What do you think led to the operation?” Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Leading question  usually closed ended and directs the client’s answer  used in a directive interview, Gives the client less opportunity to decide. create problems, gives inaccurate responses. This can result in inaccurate data. Examples are “You’re stressed about surgery tomorrow, aren’t you?” Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Try to avoid asking “why” questions PLEASE SEE THE TABLE 11-6 PAGE 165 Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Factors in Interview Setting Time – Physically comfortable ,Client free of pain – Limited interruptions Place – Well -lighted, well-ventilated – Private – Free of noise, movements – Comfortable environment – Limited distractions Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved. Factors in Interview Setting (cont’d) Seating arrangement – Hospital \ Office\ clinic – When a client is in bed, the nurse can sit at a 45- degree angle to the bed. This position is less formal than sitting behind a table or standing at the foot of the bed. Distance – Comfortable – Should be neither too small nor too great, because people Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved. Factors in Interview Setting (cont'd) Language – Use easily understood terms – Interpreter or translator Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Interview Stages Opening the most important part of the interview establish rapport( creating goodwill and trust) , orient client It can begin with a greeting (“Good morning, Mr. Johnson”) or a self introduction (“Good morning. I’m Becky James, a nursing student”) accompanied by nonverbal gestures such as a smile, a handshake. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Body – Client communicates what he or she thinks, feels, knows, and perceives in response to questions from the nurse, Nurse ask questions The nurse use communication techniques that make both parties feel comfortable Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Closing – nurse ends interview when necessary information is collected, In some cases, a client terminates it. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  The following techniques are commonly used to close an interview: 1. Offer to answer questions: “Do you have any questions?” 2. Conclude by saying “Well, that’s all I need to know for now”. 3. Thank the client: “Thank you for your time and help. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved. 4. Express concern for the person’s welfare and future: “I hope all goes well for you.” 5. Plan for the next meeting, if there is to be one, or state what will happen next. 6. Provide a summary to verify accuracy and agreement Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Methods of Data Collection 3. Examining (physical examination) – Systematic data-collection method – Uses observation and inspection, auscultation, palpation, and percussion – Vital signs, height and weight – Cephalocaudal approach: head-to-toe approach begins the examination at the head; progresses to the neck, thorax, abdomen, and extremities; and ends at the toes – Screening examination (review of systems) :a brief review of essential functioning of various body parts or systems Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Organizing data The nurse uses a written (or electronic) format that organizes the assessment data systematically. This is often referred to as a nursing health history, nursing assessment, or nursing database form. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Validating Data The information gathered during the assessment phase must be complete, factual, and accurate because the nursing diagnoses and interventions are based on this information. Validation is the act of “double-checking” or verifying data to confirm that it is accurate and factual. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved. Validating data helps the nurse complete these tasks: Ensure that assessment information is complete. Ensure that objective and related subjective data agree. Obtain additional information that may have been overlooked. Differentiate between cues and inferences Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Cues are subjective or objective data that can be directly observed by the nurse; Inferences are the nurse’s interpretation or conclusions made based on the cues.  Avoid jumping to conclusions and focusing in the wrong direction to identify problems. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Documenting the Assessment Record client data Record in factual manner; do not state interpretations Record subjective data with quotes in client’s own words Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.