Nursing Process Assessment(1) - Tagged.pdf

Nursing Process: Assessment What is an assessment?  Systematic method of collecting data about a patient for the purpose of determining the patient’s current and ongoing health status, predicting risks to health, and identifying health-promoting activities  Problems  P...

Nursing Process: Assessment What is an assessment?  Systematic method of collecting data about a patient for the purpose of determining the patient’s current and ongoing health status, predicting risks to health, and identifying health-promoting activities  Problems  Physical  Social  Cultural  Environmental  Emotional Subjective and Objective Data Subjective Data Objective Data  Verbal information from  Obtained through patient or family assessment. The actual members about the gathering of physical patient’s needs, health information from the condition, practices, patient. values, history, or life  Signs style.  Example: Vital signs  Symptoms  Example: Patient complaining of jaw pain Sources of Information Primary Secondary  Patient  Family members  Other support people  Other healthcare professionals  Records and reports  Lab and diagnostic analysis Cues and Inferences Cue Inference  Information you collect  Your judgement  Signs and symptoms Cues and Inferences HIPAA  HealthInformation Portability and Accountability Act  Confidentiality  Verbal  Written  Computer – EHR (Electronic Health Record) Types of Assessments  1. Comprehensive Admission Assessment  Comprehensive/lengthy  Collected once upon coming into an organization  2. Focused Assessment or Problem Focused Assessment  Identify and isolate our data and information gathering to the main areas of patient concerns.  Often body system focused  Occurs after the Comprehensive Admission Assessment, unless there is an urgent or emergent situation Practice  Patient complaining of constipation.  Where will this focused assessment be?  Patient complaining of feeling light-headed and dizzy  Where will the focused assessment be targeted? Practice Question  During the initial interview, the nurse notices that the patient is grimacing and will not make eye contact. The nurse wants to get more information. Which question is most appropriate to help the nurse assess the patient?  A. Tell me how you are feeling. B. Do you feel like you are going to vomit? C. Do you hurt? D. Do you need pain medicine? Answer  The best answer is A.  A. is a board open-ended statement that encourages the patient to provide more than a single word answer  How you ask questions is critical to gathering good assessment information Example Scenario  Patient was admitted to the nursing unit with a chief complaint of leg pain and edema  Patient now states he is experiencing chest pain when getting out of bed. Nurse must analyze the assessment findings.  Critical thinking by the nurse:  Is chest pain an expected finding for this patient?  Nurse: Analysis: yes /no  Nurse: Analysis: take action/no action