Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Chapter 16 Nursing Assessment

2Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Five-Step Nursing Process

3Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process  The nursing process is a variation of scientific reasoning.  Practicing the five steps of the nursing process allows you to be organized and to conduct your practice in a systematic way.  You learn to make inferences about the meaning of a patient’s response to a health problem or generalize about the patient’s functional state of health.  Through assessment, a pattern begins to form.

4Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Critical Thinking Approach to Assessment  Assessment involves collecting information from the patient and from secondary sources (e.g., family members), along with interpreting and validating the information to form a complete database.  Two stages of assessment:  Collection and verification of data  Analysis of data

5Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study  Ms. Carla Thompkins is being admitted to the medical-surgical unit as a postop patient. Ms. Thompkins, a 52-year-old schoolteacher, is recovering from a below-the-knee amputation (BKA) secondary to complications of type 2 diabetes.  Ms. Thompkins is admitted to the unit not only so her recovery from the BKA may be monitored, but also because Ms. Thompkins is going to receive preliminary occupational and physical therapy to help her adapt to the amputation.

6Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Database  The purpose of assessment is to establish a database about the patient’s perceived needs, health problems, and responses to these problems.  In addition, the data reveal related goals, experiences, health practices, values, and expectations about the health care system.  Critical thinking skills help you to synthesize relevant information and use it in a purposeful way.

7Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Data Collection  Sources of data  Patient (interview, observation, physical examination)—the best source of information  Family and significant others (obtain patient’s agreement first)  Health care team  Medical records  Scientific literature  Nurse’s experience  Subjective vs. objective data

8Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Cues and Inferences

9Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Comprehensive Assessment Approaches  Use of a structured database format, based on an accepted theoretical framework or practice standard  Example: Gordon’s model of functional health patterns  Problem-oriented approach  Assessment moves from general to specific.

10Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Process of Assessment  Collect data.  Cluster cues, make inferences, and identify patterns and problem areas.  Critically anticipate.  Be sure to have supporting cues before making an inference.  Knowing how to probe and frame questions is a skill that grows with experience.

11Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Methods of Data Collection  Patient-centered interview = An organized conversation with the patient  Set the stage (preparation, environment, greeting).  Set an agenda/gather information about patient’s concerns.  Collect the assessment or nursing health history; assure the patient of confidentiality.  Terminate the interview (cue the end).

12Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Interview Techniques  Open-ended vs. closed-ended questions  Back-channeling  Probing  Because a patient’s report includes subjective information, validate data from the interview later with objective data.  Obtain information (as appropriate) about a patient’s physical, developmental, emotional, intellectual, social, and spiritual dimensions.

13Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  During the assessment, Ms. Thompkins complains of pain at the incision site.  Ms. Thompkins’ report of pain is an example of what type of data?

14Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Cultural Considerations  To conduct an accurate and complete assessment, you need to consider a patient’s cultural background.  When cultural differences exist between you and a patient, respect the unfamiliar and be sensitive to a patient’s uniqueness.  If you are unsure about what a patient is saying, ask for clarification to prevent making the wrong diagnostic conclusion.

15Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Quick Quiz! 1. A patient is admitted to the hospital with shortness of breath. As the nurse assesses this patient, the nurse is using the process of A. Evaluation. B. Data collection. C. Problem identification. D. Testing a hypothesis.

16Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Health History

17Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Next Assessment Steps  Physical examination = An investigation of the body to determine its state of health  Observation of patient behavior (verbal vs. nonverbal)  Diagnostic and laboratory data  Interpreting and validating assessment data. Validation of assessment data consists of comparison of data with another source to determine accuracy of the data.

18Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Which of the following statements or questions made by Yolanda to Ms. Thompkins addresses the nature of Ms. Thompkins’ pain? (Select all that apply.) A. “Describe your pain to me.” B. “Is the pain worse in the morning or in the evening?” C. “Place your hand over the area that is uncomfortable.” D. “Rate your pain on a scale of 0 to 10.”

19Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Data Documentation The last component of a complete assessment Legal and professional responsibility Requires accurate and approved terminology and abbreviations

20Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Quick Quiz! 2. The nursing process organizes your approach to delivering nursing care. To provide care to your patients, you will need to incorporate nursing process and A. Decision making. B. Problem solving. C. Interview process. D. Intellectual standards.

21Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  True or False: Yolanda knows that the best source of information regarding Ms. Thompkins’ care is the surgeon.

22Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Concept Mapping A visual representation that allows nurses to graphically illustrate the connections between a patient’s health problems Allows nurses to obtain a holistic perspective of health care needs