Assessment Chapter 11

11-2 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Assessment  Assessment is the first step in the nursing process and includes systematic collection, verification, organization, interpretation, and documentation of data for use by health care professionals.

11-3 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Purpose of Assessment  To determine the client’s functional abilities and the absence or presence of dysfunction.  Identification of the client’s skills, abilities, and behaviors available to promote treatment and recovery.  Establish a therapeutic relationship.

11-4 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Types of Assessment  Comprehensive Assessment  Focused Assessment  Ongoing Assessment  Emergency Assessment

11-5 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Comprehensive Assessment  Usually completed upon admission.  Provides baseline data: Physical and psychosocial aspects Client’s perception of health Presence of health risk factors Client’s coping patterns

11-6 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Focused Assessment  Limited in scope in order to focus on a particular need or health problem.  Less detailed.  Health care agencies in which short stays are anticipated.

11-7 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Ongoing Assessment  Systematic monitoring and observation related to specific problems.  Database is broadened or confirmed.  Determine client’s response to nursing interventions.  Identify any emerging problems.

11-8 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Ongoing Assessment  Home care nurses using ongoing assessments must direct the client to provide information relevant to the current problem.

11-9 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Emergency Assessment  A rapid assessment of clients experiencing life-threatening problems or crises.  Problems can be of physiological and/or psychological and sociological nature.

11-10 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Data Collection  Uses cognitive, interpersonal, and technical skills to elicit appropriate information.  A variety of sources and methods are used in compiling a comprehensive database.

11-11 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Types of Data  Subjective Client’s perception, feelings, opinions, concerns Also referred to as symptoms Cannot be readily observed by others

11-12 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Types of Data  Objective Observable, measurable (quantitative) Also referred to as signs Standard assessment techniques Laboratory and diagnostic testing

11-13 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Sources of Data  Client, family, significant others  Medical records  Other health care professionals  Diagnostic tests  Rounds  Literature sources  Nursing knowledge

11-14 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Methods of Data Collection  Observation General appearance and behavior of the client Nonverbal cues may indicate pain, anxiety, anger or physical changes.

11-15 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Methods of Data Collection  Interview Collection of information about the client’s health history and current status in order to determine client’s health needs. Effective interviewing depends on the nurse’s knowledge and ability to skillfully elicit information from the client.

11-16 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Interview  Preparation for the Interview Review of the client’s medical records Communication with other health team members Research of the presenting medical diagnosis

11-17 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Interview Preparation  Assure adequate lighting.  Maintain comfortable room temperature.  Control for noise and distractions.  Maintain client privacy.  Establish time guidelines for interview.  Promote client comfort.

11-18 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Interview Stages  Introduction  Working  Closure

11-19 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Interview Stages  Introduction Stage Beginning of a nurse-client relationship. Introductions are made. Establishes rapport. Defines roles. Explains purpose and use of data.

11-20 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Interview Stages  Working Stage Focuses on data collection. Questions move from general to specific. Closed-ended questions yield brief answers. Open-ended questions encourage the client to elaborate about a particular concern.

11-21 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Interview Stages  Closure Stage Nurse summarizes data. Asks for validation.

11-22 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Health History  Demographic Information  Reason for Seeking Health Care  Perception of Health Status  Previous Illnesses, Hospitalizations, Surgeries  Client/Family Medical History

11-23 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Health History  Immunizations/Exposure to Communicable Disease  Allergies  Current Medications  Developmental Level

11-24 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Health History  Psychosocial History  Value and Belief System  Activities of Daily Living  Review of Systems

11-25 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Physical Examination  Baseline Data  Assessment Techniques Inspection Palpation Percussion Auscultation

11-26 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Physical Examination

11-27 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Laboratory and Diagnostic Data  Objective data that serve as defining characteristics for various altered health states.  Effectiveness of interventions and progress toward health restoration are often monitored through test data.

11-28 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Data Verification  The process by which data are validated as complete and accurate.  Data are reviewed for inconsistencies or omissions.  Subjective and objective data are examined for congruence.  Findings should be compared with norms.

11-29 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Data Organization  Data clustering is organization of the information in order to identify strengths and weaknesses.  How data is clustered depends on the assessment model used.

11-30 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Data Organization  Assessment Models Nursing Models Non-Nursing Models

11-31 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Assessment Models  Nursing Models Gordon’s Functional Health Patterns Human Response Pattern Theory of Self-care Roy Adaptation Model Leininger Sunrise Model

11-32 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Assessment Models  Non-Nursing Assessment Models Body Systems Model Hierarchy of Needs

11-33 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Data Interpretation and Documentation  Data clustering facilitates recognition of patterns and determination of further data that is needed.  Data interpretation is necessary for identification of nursing diagnoses.

11-34 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Data Interpretation and Documentation  Types of Assessment Formats Open-Ended Formats Checklist Formats Combination Formats Specialty Formats

11-35 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Sample Assessment Forms  Click one of the links below to view a sample assessment form Application: assessment in the industrial clinicApplication: assessment in the industrial clinic Sample assessment form: open-ended Sample assessment form: combination

11-36 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Specialty Formats  The MDS Medicare Prospective Payment Assessment Form (MPAF) Developed by the Health Care Financing Administration (currently CMS). Used in all skilled and long-term care facilities that are funded by CMS.