Health Assessment and the Nurse

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Learning Objectives:
After the discussion of the concept, the students will be able to: 1. Define assessment 2. Identify the role of assessment as part of the nursing process 3. Differentiate nursing assessment from medical assessment 4. Identify the role of assessment in all levels of preventive healthcare 5. Differentiate subjective and objective data

6. Differentiate primary and secondary data sources 7. Identify the factors that affect communication 8. Identify communication techniques 9.Identify the phases of interview 10.Describe data collection methods 11. Define the four techniques of physical assessment 12.Identify the methods used to validate assessment data 13. Describe the various documentation methods for charting assessment data.

Nursing- is the diagnosis and treatment of human responses to the actual and potential health problems

Diagnosis and treatment are achieved through a process, called..

Nursing Process
guides the nursing practice a systematic, rational method of planning and providing individualized nursing care used to identify, prevent and treat actual and potential health problems and promote wellness provides a framework in which to practice nursing problem-solving method that has 5 steps

Assessment Nursing Diagnosis Planning Implementation Evaluation

Characteristics of the Nursing Process Dynamic & Cyclic Patient centered Goal Directed Flexible Problem Oriented Cognitive Action oriented Interpersonal Holistic Systematic

Assessment
Is the process of collecting, validating, and clustering the data. It is the first and most important step in the nursing process This phase sets the tone for the rest of the process, the rest of the process flows from it This identifies your patients strengths and limitations, and not performed once but continuously through the nursing process

Assessment
Has been identified by the American Nurses Association (ANA) as the first Standard of Nursing Practice. The Standard describes assessment as the systematic, continuous collection of data about the health status of patients. Nurses are responsible not only for data collection but also for making sure that the data are accessible, communicated and recorded. An ongoing process

Purposes of Assessment
Collect data pertinent to the patients health status Identify deviations from normal Discover the patients strengths and coping resources Pinpoint actual problems Spot factors that place the patient at risk for health problems

Skills of Assessment
Cognitive Skills Problem-Solving Skills Psychomotor Skills Affective/Interpersonal Skills Ethical Skills

Cognitive Skills
Assessment is a thinking process These are needed for critical thinking and clinical decision making Theoretical knowledge base enables you to assess your patient holistically Knowledge base includes not only biophysical knowledge but also developmental, cultural, psychosocial, and spiritual knowledge Knowledge base enables you to differentiate normal from abnormal findings, identify and prioritize

Critical Thinking- a complex thinking process that has been defined in many ways - its reasonable thinking - not just doing, it is asking why -involves inquiry, interpretation, analysis, and synthesis - the alert art of thinking

Clinical Decision Making- as to relevance -look for the cues and make inferences -with experience, identify patterns and recognize what differs from norm and use data to make decisions what will best meet your patients needs -use your knowledge, experience and what the patient says to validate the data.

Problem-Solving Skills
1. Reflexive Thinking-is automatic, without conscious deliberation, and comes with experience 2. Trial- and- error approach-hit- or miss thinking -fosters creativity and allows you to formulate new ideas -look beyond the obvious, keep looking until you find an answer

3. Scientific Method- a systematic, critical thinking approach to problem solving - involves identifying a problem and collecting, supporting data and formulating a hypothesis, planning a solution, implementing the plan and then evaluating its effectiveness. 4. Intuition- a problem-solving method that develops through experience

Psychomotor Skills
These are needed to perform the four techniques of physical assessment: inspection, palpation, percussion and auscultation. As a beginning practitioner, you may feel unsure of your technique and findings, but practice will hone your skills. Input from others, through experience, you will become competent at performing the physical assessment and confident in interpreting the findings

Affective/Interpersonal Skills

Include both verbal and nonverbal communication skills Establishing trust and mutual respect is essential before you begin the assessment Seeing your patient as an individual and being sensitive to his or her feelings conveys a message of caring and promotes human dignity

 Interpersonal Skills are also needed to communicate with family members and members of the health team to successfully meet your patients goals

Communication
Nonverbal messages and touch Vocal cues and paralinguistics: quality of voice, inflection, tone, intensity, and speed Action cues & kinetics: body movements, posture, arm position, hand gestures, facial expression, eye contact

Communication
Object cues: grooming, dress reflect his/her identity and how he/she feels about himself or herself Personal space: public, social, and personal, the territory surrounding a person that he/she perceives as private or the physical distance that needs to be maintained for the person to feel comfortable Personal conversation is about 18 inches to 4 feet Touch- is also a means of communication

Communication Techniques
1. Affirmation/Facilitation-acknowledge your patients response through both verbal and nonverbal communication to reassure him/her that you are paying much attention to what he/she is saying, verbal cues such as ah ha, or nonverbal gestures such as nodding, leaning forward 2. Silence- it can be very effective at facilitating communication. Periods of silence allow your patient to collect her/his thoughts before responding 3. Restating-would show that you are listening 4. Clarifyingrephrase what she said by saying I want to make sure 5. Reflection when a patient expresses feelings, you echo it back in a form of question 6. Informing- giving information 7. Broad & general openings-use open-ended questions

8. Active listening 9. Humor- to reduce anxiety 10. Redirecting- redirecting your patient helps keep the communication goal-directed. It is useful if the patient goes off on a tangent. 11. Sharing perceptions- you give your interpretation on what has been said in order to clarify things and prevent misunderstandings

13. Identifying themes-this may help your patient make a connection and focus on the major theme for example, you might say From what youve told me, it sounds like every time you were discharged from the hospital to home, you has a problem 14. Sequencing events 15. Presenting reality be more realistic

 Focusing Suggesting Summarizing-allows patient to clarify any misconception you may have

How You Communicate

Genuineness- be open, honest and sincere Respect-everyone should be respected as a person of worth and value. Dont be judgmental in your approach Empathy-knowing what your patient means and understanding how he/she feels. Acknowledge patients feelings, show acceptance, care and concern

Difference Between Nursing & Medicine

Nursings Goal To diagnose and treat human responses to actual or potential health problems Medicines Goal To diagnose and treat disease

Levels of Preventive Care

Primary To focus on health promotion and illness prevention, minimize the risk of health problems ( immunization, nutritional instruction) Secondary To focus on early detection, prompt intervention, and health maintenance Tertiary To focus on rehabilitation and extended care to continually monitor health status

Assessment Data
Subjective Covert, not measurable symptoms example is health history Objective Overt, measurable signs examples are physical examination and diagnostic studies

4 Types of Assessment
1. Initial Comprehensive Assessment involves collection of subjective data about the clients perception of her health of all body parts or systems, past health history, family history, lifestyle, and health practices as well as objective data gathered during the step-by-step physical examination -examines the patients overall health status

2. Ongoing or Partial Assessment - Consist of data collection that occurs after the comprehensive data base is established - Consist of mini-overview of the clients body systems and holistic health patterns as a follow up on his health status - Brief reassessment of the clients normal body system or holistic health patterns is performed to detect any new problems

3. Focused or Problem-Oriented Assessment - Does not take the place of the comprehensive assessment - Consists of thorough assessment of a particular client problem and does not cover areas not related to the problem

4. Emergency Assessment -rapid assessment performed in lifethreatening situations(choking, cardiac arrest, drowning) -assess the ABC of patient

Methods of Data Collection:

1. The Interview Types of interviews: directive (are structured with specific questions) or non-directive (controlled by patient, although the nurse often needs to summarize and clarify the data) Types of questions: open (elicit patients perception like What brought you to the hospital?) or closed (Often that elicit a yes or no response) Interviewing tips or techniques/pitfalls

Phases of Interview
1. Introductory Phase -time to introduce yourself -put patient at ease and explain purpose of the interview and time frame needed to complete it - client may display some resistive behaviors - these behaviors inhibit involvement, cooperation or change - can be overcome by conveying a caring attitude, genuine interest, and competence - trust can be developed- involves risk, as one becomes vulnerable but enables the client to express thoughts and feelings openly

2. Working (Maintaining) Phase -data collection occurs -listen to what the patient is saying both verbally and nonverbally - begin to view each other as unique individuals - starts to care about each other

3. Termination Phase - expect some feelings of loss - needs to develop a way of saying goodbye - methods to terminate the relationship:
Summarizing or reviewing Express feelings about termination honestly and openly Needs to be discussed in advance to allow time to adjust

Methods of data Collection

2. Observation 3. Physical Examination

Data Analysis
Data review Are data accurate and complete? Data interpretation - What are the patients actual and/or potential problems? - Develop a problem list based on the data; prioritize the patients problems

ORGANIZING DATA
THE NURSE USE A WRITTEN FORMAT THAT ORGANIZES THE ASSESSMENT DATA SYSTEMATICALLY. THIS IS OFTEN REFERRED TO AS NURSING HEALTH HISTORY, NSG ASSESSMENT OR NURSING DATABASE

VALIDATING DATA
VALIDATION is the act of double checking or verifying data to confirm that it is accurate and factual
Ensure that objective and related subjective data agreed

DOCUMENTING DATA
The nurse records client data. Accurate documentation is essential and should include all collected data about clients health status data are recorded in a factual manner.

Definitions A. Medical Diagnosis identification of a disease condition based on a specific evaluation of physical signs, symptoms, history, laboratory test and procedures. B. Nursing Diagnosis a statement that describes the clients actual or potential response to a health problem that the nurse is licensed and competent to treat.

Purposes of Nursing Diagnosis

A. To analyze assessment data. B. Identify health problems involving the client and family. C. Provide direction for the nursing care plan (NCP).

Actual Nsg Dx= Patient Problem+Cause if known PROBLEM Impaired skin integrity CAUSE Physical immobilization, low oxygen saturation

Impaired verbal communication

Inability to speak dominant language

PES APPROACH Nsg Dx= Problem+Etiology+ Signs & Sx 1. Impaired Skin integrity related to physical immobilization, low saturation, and incontinence as manifested by disruption of the skin surface over the elbows
2. Impaired verbal communication related to cultural differences as manifested by inability to speak English

Steps in Nursing Diagnosis

A. Analyze and interpret data recognize
patterns and trends, comparing these with normal health patterns and drawing conclusions about the clients response.

1. Examine the clusters in the data base. 2. When a relationship is identified, a list of client-centered problems/needs will emerge. 3. Group together the cluster and patterns consisting of defining characteristics

B. Identify client problems consider all assessment data and focus on pertinent and abnormal data. In describing health problem, the nurse moves from general to specific.

 Planning- is a category of nursing behaviors in which a clientcentered goals and strategies are designed to achieve goals.

Steps in Planning
A. Establish priorities.-Nursing diagnosis are ranked mutually by the nurse and the client in order of importance (based on clients desires, needs and safety) so as to identify, also in order, the nursing interventions to be provided especially when the client has multiple problems

 1. Maslows hierarchy of needs is useful in determining priorities. Physiological needs are given priority over safety needs. .

2. Classification 2.1 High- nursing diagnosis that if untreated, could result in harm to client or others 2.2 Intermediate- involve the non emergency, non life threatening needs of the client 2.3 Low- clients needs that may not be directly related to a specific illness or prognosis 3. In situations when the client and nurse assign different priority ranking, it should be resolved through open communication

B. Establish Goal and expected outcomes. Goals and expected outcomes are specific statements of client behaviors or responses that the nurse anticipates from nursing care. Include not only immediate, but also prevention and rehabilitation needs.

 1.Definitions 1.1 Goals-guideposts to the selection of nursing interventions and criteria in the evaluation of nursing interventions 1.2 Client centered goal- a specific and measurable objective designed to reflect the clients highest level of wellness and independence in function

 1.3 Expected outcome- specific step by step objective that leads the attainment of the goal and the resolution of the cause of nursing problem -Involves the physiological, social, emotional, developmental or spiritual dimensions -Determines when the specific, client centered goal has been met and assists in evaluating the response to nursing care and resolution of the nursing diagnosis

 2.Purposes 2.1 They provide direction for the individualized nursing intervention 2.2 Used to determine the effectiveness of the interventions .They identify a specific means to evaluate the clients response to nursing care

 3.Types of Goals
3.1 Short Term Goal- an objective that is expected to be achieved in a short period of time, usually less than a week. It is usually the aim of the immediate care plan. E.g , a a short term goal for Ineffective thermoregulation is Body temperature 37C within an hour after tepid sponge bath 3.2 Long-term goal- an objective that is expected to be achieved over a longer period of time, usually over weeks or months. Are appropriate for problem resolution after discharge.

 4. Functions of expected outcomes

4.1 Provide a direction for nursing activities. 4.2 Provide a projected time span for goal attainment and an opportunity to state any additional resources that may be required to achieve the goal, including additional equipment, personnel or knowledge. 4.3 Serve as criteria to evaluate the effectiveness of nursing activities.

5. Guidelines for writing goals and expected outcomes.

5.1 Should be client-centered. e.g The newly delivered mother will breastfeed her newborn baby on demand. i.e Whenever the baby is hungry . 5.2 Should address only one behavioral response at a time so as to provide a more precise method to evaluate client response to the nursing action.

 E.g Clients temperature will decrease to 37C and respiratory rate will be 16-20 minute 1 hour after administration of ordered antipyretic should be split into two: Temperature will decrease and Respiratory rate will be

 5.3 Expected outcome should be observable e.g Bowel movement will decrease in frequency after 24 hours. 5.4 should contain outcome criteria and are written to give the nurse a standard against which to measure the clients response to nursing care. Terns specifically describing quality, quantity, frequency and weight allow the nurse to evaluate the expected outcome. Value qualifiers like normal, acceptable or sufficient are not allowed. E.g Blood pressure will return to 120/80 mm Hg a day after administration of antihypertensive drug. 5.5 A time frame is necessary for each goal and expected outcome.

Write the Nursing Care Plan

Definition: A written guideline for client care. Contents 2.1 Nursing diagnoses 2.2 Goals 2.3 Specific nursing activities and strategies 2.4 Expected outcomes

Purposes 3.1 Documents the clients health care needs, which are determined by assessment and the nursing diagnoses, priorities and goals and expected outcomes formulated during planning.
3.2 Coordinates nursing care, promotes continuity of care and list outcome criteria to be used in the evaluation of nursing care.

3.3 Communicates to other nurses and health care professionals pertinent assessment data, a list of problems and therapies.

 3.4 makes possible the coordination of nursing care, subsequently consultations and scheduling of diagnostic tests.
3.5 Identifies and coordinates resources used to deliver nursing care. 3.6 Enhance the continuity of nursing care by listing specific nursing actions necessary to achieve the goals of care.

 3.7 Organizes information exchanged by nurses in change-of-shift reports.

3.8 Can be adapted to the discharge needs of the client. 3.9 provides direction for implementation of the plan and a framework for evaluation of the clients response to nursing actions.

Types of NCPs
Institutional care plans concise documents that become part of the clients medical record. Many hospitals use the Kardex, a trade name for a card-filing system that allows quick reference to the particular needs of the client for certain aspects of nursing care: diet, medications, activity level, level of self-care, treatments and procedures.

 Standardized care plans forms created for a specific clinical area, (e.g ICU, OPDs, DRs) in order to streamline and augment care planning. They are not intended to replace the NCP but to avoid a situation in which are not nurse must write the same generalized plan again

Students NCPs essential for learning the

problem-solving technique, the nursing process, skills of written and verbal communication and organizational skills needed for nursing care. Students are able to apply the theoretical knowledge to a practice situation. In fact is more elaborate than the first two, consisting of 5 columns: assessment, goals, implementation, rationale (the reason that, based on supporting literature, a specific nursing action was chosen) and expected outcomes.

 Definition- a category of nursing behavior in which the actions necessary for achieving the expected outcomes of nursing care are initiated and completed. It includes:

 Performing, assisting or directing the performance of activities of daily living. (ADL) Counseling and teaching the client and family Giving direct care to achieve client centered goals

Nursing Action or Intervention

any act by the nurse that implements the nursing care plan (NCP) or any specific objective of the plan. It may be in form of support, medication, treatment for the current condition or to prevent future health problems or client family education

Types of Nursing Intervention

A. Independent nursing actions
-involves aspects of professional nursing practice which do not require supervision or direction from others as encompassed by applicable license and law

 B. Interdependent Nursing Actions - carried out by the Nurse in collaboration with another health care professional. Collaboration is a partnership wherein the power on both sides is valued by both

 Dependent nursing actions - are based on the instruction or written orders of another professional, the implementation of which requires specific nursing responsibilities and technical nursing knowledge.

An ongoing, dynamic and ever changing component of the nursing process which measures the clients response to nursing actions performed and the level of success in achieving clients goals. In other words, It ensures quality professional nursing practice.

Degrees of Goal Attainment

a. Met Goal- if the clients response matches or exceed the outcome criteria b. Partially met goal- if the clients behavior begins to show changes but does not yet meet specified criteria c. Unmet goal- there is no progress at all

Documentation Methods
Consider the following assessment of Mary Rutherford: after a cholecystectomy. Her assessment data include the following: >it hurts to take a deep breath >pain rated 8/10 >guarding abdomen >v/s BP 144/90mmhg,PR-108bpm,RR-24cpm,T38 degree Celcius >decreased breath sounds >dressing dry and intact

SOAPIE Method
Subjective data Objective data Assessment/Clinical judgment-Ineffective breathing pattern related to incisional pain Plan-pt will establish effective breathing pattern; pt will experience no signs of respiratory complications Interventions-encourage coughing and deep breathing, encourage ambulation, maintain adequate hydration Evaluation-patient coughing and deep breathing, ambulating, v/s

DAR Method
Data Action Response

PIE Method
Problem-Ineffective breathing pattern related to incisional pain Interventions Evaluation

Narrative Method
4/14/09 8AM. Patient stated It hurts to take a deep breath, rates pain 8/10, v/s BP 144/90 mmHg, T- 38 degree Celcius,pr 108, RR 24, 9AM. Patient coughing and deep breathing, ambulating with assistance