Nursing Assessment

Nursing assessment thinking about what information to collect collecting information thinking about the significance of that information drawing conclusions about how the patient is responding to his or health or illness condition

Nursing assessment: 2 steps Collecting and verifying data from the patient and family members Patient: the primary source of information Family, medical records, other health professionals: secondary sources of information Analyzing the data to determine the plan of care for the patient

Databases The purpose of nursing assessment is to develop a database about the client’s health status Patient’s perceived needs and health problems Patient’s responses to these problems The database also provides other information about the patient’s: Related experiences Health practices Goals Values Expectations about the health care system

Assessment-six steps collecting data identifying cues and making inferences validating data organizing (clustering data) identifying patterns/testing first impressions reporting and recording data

Database vs. focus assessment Database assessment Standardized start-of-care assessment tool for each patient – includes information about all body systems and issues important to the patient’s health Comprehensive and accurate data base assessment system that is standardized and reproducible Focus assessment Data gathered to determine the status of a specific condition For example: a diabetic’s blood sugar history or a patient’s eating habits

Objective data Observations or measurements that are made by the nurse Examples: Size of a wound or lesion Blood pressure, temperature, pulse rate Amount of urine output If it can be measured with equipment or sensors, it is objective data

Subjective data Data that can only be provided by the patient Feelings, impressions, sensations, beliefs, attitudes Anxiety, pain, mental stress, relief, joy, grief Only patients can provide subjective data about their feelings, although some problems may result in physiological changes that can be measured objectively For example: severe pain will often cause increased heart rate and blood pressure

Patient interview Good for getting information about: “What brings you here” (chief complaint) Health history Introduce yourself Be professional but be pleasant Be sure to state your position (RN, student nurse, etc.) Patients usually love student nurses- don’t be afraid to let them know that you are a student!

Patient interview Sometimes patients are not too keen on admitting why they are there- Patients sometimes have embarrassing reasons for seeking health care Don’t be judgmental, don’t show emotion- just be professional and supportive to the patient You can let your emotions out later, away from the patient!

Patient interview It is usually best to do the health history first, before doing a physical examination The patient will get to know you a bit and start to become comfortable with you before invasive/intrusive examination procedures begin Try to do the patient interview where you won’t be interrupted or overheard

Patient interview Try to be yourself, and relax so that you can put the patient at ease as much as possible If you appear stiff and tense, the patient will feel the same way Go through your questions carefully, and pay attention to the patient’s answers Don’t become so engrossed in writing down answers that you miss the patient’s body language

Putting patients at ease When I meet new patients who are anxious, I try to find some area that we have in common- crossword puzzles, TV, movies, whatever- to help put them at ease I also have a variety of uniforms with cartoon characters on them (Garfield, Snoopy, Bugs Bunny) that help to break the ice with new or anxious patients Once patients are comfortable talking with you about a safe topic, then they will usually be more comfortable talking about topics of a more sensitive nature

A note about working with patients I think that the best part of nursing is the nurse-patient relationship When the nurse realizes that the patient is a person with real thoughts and feelings, and the patient realizes the same about the nurse, a special connection forms That connection is what makes nursing really great for me… An interaction begins that goes beyond a job- it becomes a helping relationship between two people that leaves the nurse and the patient better because of the encounter

Patients When working with patients and their families, you often will get front-row seats to some of the best and worst times of their lives It is important to be supportive and empathetic but not become dragged down by their grief or loss Patients and families may get angry, upset or frantic- Be supportive and professional. Sometimes it helps to just let the patient or family vent their feelings. Do what you can and don’t take it personally.

Validating (verifying) data verifying that your data is factual and complete need to avoid: making assumptions missing key information misunderstanding situation jumping to conclusion or focusing in the wrong direction making errors in problem identification

Once you have your data verified… You need to organize it! Some facilities will have forms to fill out that have everything organized. Sometimes you will have to do it yourself. There are lots of ways to organize your data Can organize head to toe (useful for physical assessments) Or into groups like Gordon’s Functional Health Patterns

Gordon’s Functional Health Patterns -may be used to organize assessment data Health perception & management Activity & exercise Nutrition & metabolism Elimination Sleep and Rest Cognition & perception Self-perception & self-concept Roles & relationships Coping & stress management Sexuality & reproduction Values & beliefs

Analyzing data Once you have your data organized, you will want to look through it to identify patterns For instance- you might notice that the patient… Smokes 2 packs per day Has a congested cough and wheezes Gets short of breath easily This patient obviously has some respiratory issues going on, so you can: Consider respiratory-related nursing diagnoses Do some additional physical assessments- check the patient’s oxygen saturation, look for nail clubbing, etc. This is where critical thinking comes in!!!

Documenting Be sure to document all of your findings from the interview/health history and physical examination. Make notes while you are doing the interview and assessment, and save the rest for afterward Patients don’t like to sit and watch you write long notes about them When you are at clinical - any abnormal, unusual, or unexpected findings must be reported to your instructor in addition to being documented in the patient’s chart!