Nursing Assessment Ch 11

Front 1

Types of ASSESSMENT

Back 1

Initial - admission assessment

Focus - collects data about a problem already identified.

Time-lapsed - evaluate any changes in the client's functional health.

Emergency - identification of life-threatening situation.

Front 2

Aim of
INITIAL ASSESSMENT

Back 2

Initial identification of
normal function, functional status, and collection of data concerning
actual or potential dysfunction.
Baseline for reference & future comparison.

Within specified time frame after admission.

Front 3

Aim of
FOCUS ASSESSMENT

Back 3

Collects data about a problem already a identified.
Narrower scope & shorter time frame. A few min to few hours bet assessment.

Front 4

Aim of
TIME-LAPSED REASSESSMENT

Back 4

Evaluate any changes in the client's functional health.
Several months bet assessments.

Front 5

Aim of
EMERGENCY ASSESSMENT

Back 5

Identification of life-threatening situation.

Anytime a physiologic, psychological, or emotional crisis occurs

Front 6

OBSERVATION

Back 6

Uses vision, smell, hearing, touch.
Vision - "looks"
Smell - fruity = ketosis in diabetes mellitus
Hearing - client's response provide cues about mental & physical condition.
Touch - provide nonverbal comm & reassurance. - always consider the client's sociocultural background when using touch

Front 7

4 Phases of Interviewing

Back 7

PREPARATORY - prepare & plan before meeting client
INTRODUCTORY - orientation, goals are stated, discuss purpose, establish rapport, clarify goals, alleviate anxiety
WORKING/MAINTENANCE - focus on data collection (past & current health), general or specific - nurses responsibility to make sure goals are met
CONCLUSION - indicate closure, summarized - review goals/tasks and express concerns

Front 8

PHYSICAL ASSESSMENT - 4 techniques

Back 8

* Inspection
* Palpation
* Percussion
* Auscultation

Front 9

INSPECTION

Back 9

Visual examination done in a methodical & deliberate manner.
Factors such as color, shape, symmetry, movement, pulsations and texture of the involved body part are noted.

Front 10

PALPATION

Back 10

Specialized use of touch for data collection.
- use fingertips and palms to determine the size, shape and configuration of underlying body structures
- pulsations and or vibrations of blood vessels, outlines of organs, size, shape, motility of masses, tenderness or sensitivity

Front 11

PERCUSSION

Back 11

1 or both hands are used to strike the body surface to produce a sound called percussion.
Used to discover location & level of organs (liver, hear, diaphragm), consistency of body structures, presence of tenderness, identification of massess or tumors

Front 12

AUSCULTATIONS

Back 12

Listening to body sounds with a stethoscope placed on the body surface to amplify normal & abnormal sounds.

Front 13

INTUITION

Back 13

Use of insight, instinct, and clinical experience to make clinical judgments about the client.
- plays a role in the nurse's ability to analyze cues rapidly, make clinical decisions, and implement nursing actions even though nursing data may be incomplete or ambiguous
- comes into play when assessment data are incomplete, sketchy or vague, or when the client looks all right on the surface but the nurse senses that something is not quite right

Front 14

Method of Collecting
SUBJECTIVE data

Back 14

Interview
- best recorded as direct quotations from the client
"every time I cough, I pee a little and it makes me sad"

Front 15

Method of Collecting
OBJECTIVE data

Back 15

Inspection, palpation, auscultation, percussion
Measurement devices
Health record
Lab studies, radiologic tests, diagnostic procedures

Front 16

Examples of
SUBJECTIVE data

Back 16

Symptoms, values, perceptions, feelings, attitudes, sensations, beliefs

Front 17

Examples of
OBJECTIVE data

Back 17

Phy examination findings: heart sounds, palpable tumor, discolored skin
BP, temp, intracranial pressure
Written reports
CBC, chest radiography results

Front 18

SECONDARY SOURCE
of data

Back 18

* Family or significant other
* Nursing records
* Medical records
* Consultations
* Health care team members
* Diagnostic results
* Relevant literature

Front 19

VALIDATION

Back 19

Confirming the accuracy of assessment data collected
- double-checking the data at hand
- assists in verifying and clarifying cues and inferences, thus increasing the likelihood that cues and inferences are accurate, free from bias, and interpreted correctly

Front 20

Methods of VALIDATING data

Back 20

* Compare cues to normal function
* Refer to textbooks, journals & research reports
* Checking consistency of cues
* Clarifying client's statements
* Seeking consensus with colleagues about inferences.

Front 21

FUNCTIONAL HEALTH PATTERNS Model

Back 21

Focus on client's normal function and his/her altered function or risk for altered function.

Front 22

HEAD-to-TOE Model

Back 22

Examine every part of the body starting from the head and down to the toes.

Front 23

BODY SYSTEMS Model
(Medical model)

Back 23

Focuses on the client's major anatomic systems.

starts with an assessment of the client's general state of health, followed by systematic assessment of each body system (neurologic, cardiovascular, respiratory, gastrointestinal, and so on) until all systems have been assessed

Front 24

Assessment is done for the following reasons:

Back 24

* To establish baseline information on the client
* To determine the client's normal function
* To determine the client's risk for dysfunction
* To determine the presence or absence of dysfunction
* To determine the client's strengths
* To provide data for the diagnosis phase

Front 25

ASSESSMENT

Back 25

the first phase of the nursing process
the collection of data for nursing purposes. Information is collected using the skills of observation, interviewing, physical examination, and intuition and from many sources, including clients, their family members or significant others, health records, other health team members, and literature review.

Front 26

CUES

Back 26

pieces of information about a client's health status
may be subjective (symptoms) or objective (signs)

Front 27

The Nursing History helps the nurse:

Back 27

* Clarify and verify the client's perception of his or her health status
* Compare the client's present and past health status, lifestyle behaviors, and coping abilities
* Identify actual and potential nursing diagnoses
* Develop the client plan of care
* Implement nursing interventions to support the client's adaptive responses

Front 28

Facilitators of Communication

Back 28

use broad opening statements - give general leads - listen - acknowledge the client's feelings - use silence - give information - reflect or repeat the client's words - share observations - clarify - summarize - validate - verbalize implied thoughts or feelings

Front 29

Barriers to Communication

Back 29

make stereotyped comments - give advice or state your opinion - agree with the client - defend - give approval - use reassuring cliches - request an explanation - express disapproval - belittle the client's feelings - change the subject - disagree with the client - appear inattentive, impatient, or distracted

Front 30

PRIMARY SOURCE of data

Back 30

the client
only they can give a first-hand description of the health problem and it's affects on his or her lifestyle

Front 31

PRIMARY SOURCE best source of data unless:

Back 31

unless circumstances such as altered level of consciousness, severe pain, impending surgery, acute illness, or age make data collection impossible. The client is deemed unreliable if he or she is confused or suffering from physical or mental conditions that alter thinking, judgment, or memory. In these situations, secondary sources help provide the necessary assessment information.

Front 32

SECONDARY SOURCE is good when:

Back 32

- client forgets to mention or is unwilling to reveal information
- working with children
- get client's permission when possible to obtain information from family or significant others
- Health record may reveal data not expressed by the client or picked up by the nurse

Front 33

Organize Data - Frameworks

Back 33

serve as guides during the nursing interview and physical examination, help prevent the omission of pertinent information, and foster data analysis in the diagnosis phase

Front 34

Advantages of a Functional Health Framework

Back 34

* Client strengths and assets (not merely deficits, problems, or limitations) can be identified.
* The focus is on nursing diagnoses, not medical diagnoses.
* Clustering is easier to do because of the simple categories and concise typology.
* It may contribute to the delineation of basic assessment areas relevant for all clients.

Front 35

11 Functional Health Patterns

Back 35

1- Health perception and health management. 2- Activity and exercise. 3- Nutrition and Metabolism. 4- Elimination (pee, poo, sweat). 5- Sleep and rest. 6 - Cognition and perception. 7- Self-perception and Self-concept. 8- Role and Relationships. 9- Coping and Stress Tolerance. 10- Sexuality and Reproduction. 11- Values and Beliefs