1. 11
Assessing

2. Directory Classroom Response System Questions
Lecture Note Presentation

3. Classroom Response System Questions

4. Question 1
Which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process?
Identifying major problems or needs
Organizing data in the client’s family history
Establishing short-term and long-term goals
Administering an antibiotic

5. Question 1 Answer Identifying major problems or needs
Organizing data in the client’s family history
Establishing short-term and long-term goals
Administering an antibiotic

6. Question 1 Rationales
Correct. Identifying problems/needs is part of nursing diagnosis. For example, a client with difficulty breathing would have a nursing diagnosis of Impaired Gas Exchange related to constricted airways as manifested by shortness of breath (dyspnea).
Organizing family history is part of the assessment phase.
Establishing goals is a part of the planning phase.
Administering an antibiotic is part of the implementation phase.

7. Question 2
Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care?
Proposes hypotheses
Generates desired outcomes
Reviews results of laboratory tests
Documents care

8. Question 2 Answer Proposes hypotheses Generates desired outcomes
Reviews results of laboratory tests
Documents care

9. Question 2 Rationales Hypotheses are generated during diagnosing.
Outcomes are set during planning.
Correct. During assessment, data are collected, organized, validated, and documented.
Documentation occurs throughout the nursing process.

10. Question 3
Which of the following elements is best categorized as secondary subjective data?
The nurse measures a weight loss of 10 pounds since the last clinic visit.
Spouse states the client has lost all appetite.
The nurse palpates edema in lower extremities.
Client reports severe pain when walking up stairs.

11. Question 3 Answer
The nurse measures a weight loss of 10 pounds since the last clinic visit.
Spouse states the client has lost all appetite.
The nurse palpates edema in lower extremities.
Client reports severe pain when walking up stairs.

12. Question 3 Rationales
Weight is objective data that can be measured or validated.
Correct. Secondary data comes from any other source (chart, family) besides the client. Subjective data are covert (reported or an opinion).
Edema is objective data that can be measured or validated.
What the client reports is primary data.

13. Question 4
The nurse wishes to determine the client’s feelings about a recent diagnosis. Which interview question is most likely to elicit this information?
“What did the doctor tell you about your diagnosis?”
“Are you worried about how the diagnosis will affect you in the future?”
“Tell me about your reactions to the diagnosis.”
“How is your family responding to the diagnosis?”

14. Question 4 Answer “What did the doctor tell you about your diagnosis?”
“Are you worried about how the diagnosis will affect you in the future?”
“Tell me about your reactions to the diagnosis.”
“How is your family responding to the diagnosis?”

15. Question 4 Rationales This question just seeks factual information.
This question can be answered with a single word.
Correct. Eliciting feelings requires open-ended questions that seek more than just factual information and cannot be answered with a single word.
The family can provide indirect information about the client but is not likely to provide the most accurate information.

16. Question 5
The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following?
Correlation of the data with other members of the health care team
Demonstration of cost-effective care
Utilization of creativity and intuition in creating a plan of care
Collection of all necessary information for a thorough appraisal

17. Question 5 Answer
Correlation of the data with other members of the health care team
Demonstration of cost-effective care
Utilization of creativity and intuition in creating a plan of care.
Collection of all necessary information for a thorough appraisal

18. Question 5 Rationales
Other members of the health care team may use very different conceptual organizing frameworks, so data may not correlate.
Cost-effective care is more likely to occur with systematic application of the nursing process, but use of a framework for assessment alone may not accomplish this goal.
Because the framework is structured and because of the nature of client needs/problems, creativity and intuition in care planning are not assured.
Correct. Frameworks help the nurse be systematic in data collection.

19. Lecture Note Presentation

20. Learning Outcomes Describe the phases of the nursing process.
Identify major characteristics of the nursing process.
Identify the purpose of assessing.
Identify the four major activities associated with the assessing phase.

21. Learning Outcomes (cont'd)
Differentiate objective and subjective data and primary and secondary data.
Identify three methods of data collection and give examples of how each is useful.
Compare directive and nondirective approaches to interviewing.

22. Learning Outcomes (cont’d)
Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each.
Describe important aspects of the interview setting.
Contrast various frameworks used for nursing assessment.

23. Nursing Process Overview
Nursing process – systematic, rational method
Five or six phases
Assessing
Diagnosing
Identifying outcomes (sometimes included)
Planning
Implementing
Evaluating

24. Figure 11-1 The nursing process in action.24

25. Figure 11-1 (continued) The nursing process in action.25

26. Characteristics of the Nursing Process
Cyclic and dynamic rather than static
Client centered
Problem-solving and systems theory
Decision making

27. Characteristics of the Nursing Process (cont’d)
Interpersonal and collaborative
Universal applicability
Critical thinking skills

28. Figure 11-3 Assessing. The assessment process involves four closely related activities.28

29. Assessing Data (information) gathered systematically
4 types of assessment
Initial nursing assessment
Problem-focused assessment
Emergency assessment
Time-lapsed reassessment

30. Types of Assessments Initial Problem-Focused
Performed within a specified time period
Establishes complete database
Problem-Focused
Ongoing process integrated with care
Determines status of a specific problem

31. Types of Assessments (cont'd)
Emergency
Performed during physiologic or psychologic crises
Identifies life-threatening problems
Identifies new or overlooked problems
Time-lapsed
Occurs several months after initial
Compares current status to baseline

32. Collecting Data Gathering information about client’s health status
Must be systematic and continuous
Includes past history and current problem
Subjective or objective
Primary or secondary source
Establishes database

33. Subjective Data Symptoms or covert data
Apparent only to person affected
Can be described only by person affected
Includes sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situations

34. Objective Data Signs or overt data Detectable by an observer
Can be measured or tested against an accepted standard
Can be seen, heard, felt, or smelled
Obtained through observation or physical examination

35. Sources of Data Primary source Secondary sources The client
All other sources of data (support people, records, other health care professionals, literature)
Should be validated, if possible

36. Methods of Data Collection
Observing
Gathering data using the senses
Used to obtain following types of data:
Skin color (vision)
Body or breath odors (smell)
Lung or heart sounds (hearing)
Skin temperature (touch)

37. Methods of Data Collection (cont’d)
Interviewing
Interview - planned communication or a conversation with a purpose
Used to:
Get or give information
Identify problems of mutual concern
Evaluate change
Teach
Provide support
Provide counseling or therapy

38. Directive Approach to Interviewing
Nurse establishes purpose
Nurse controls the interview
Used to gather and give information when time is limited, e.g., in an emergency

39. Nondirective Approach to Interviewing
Rapport-building
Client controls the purpose, subject matter, and pacing
Combination of directive and nondirective approaches is usually appropriate during information-gathering interview

40. Types of Interview Questions
Closed questions
Restrictive
Yes/no
Factual
Less effort and information from client
“What medications did you take?”
“Are you having pain now?”

41. Types of Interview Questions (cont’d)
Open-ended questions
Specify broad topic to discuss
Invite longer answers
Get more information from client
Useful to change topics and elicit attitudes
Neutral question
Leading question

42. Factors in Interview Setting
Time
Client free of pain
Limited interruptions
Place
Private
Comfortable environment
Limited distractions

43. Factors in Interview Setting (cont’d)
Seating arrangement
Hospital
Office or clinic
Group
Distance
Comfortable

44. Factors in Interview Setting (cont'd)
Language
Use easily understood terms
Interpreter or translator

45. Interview Stages Opening – establish rapport, orient client
Body – client communicates, nurse asks questions
Closing – nurse ends interview when necessary information is collected

46. Methods of Data Collection
Examining (physical examination)
Systematic data-collection method
Uses observation and inspection, auscultation, palpation, and percussion
Vital signs, height and weight
Cephalocaudal approach
Screening examination (review of systems)

47. Frameworks for Nursing Assessment
Nursing models framework
Gordon’s functional health pattern framework
Orem’s self-care model
Roy’s adaptation model

48. Frameworks for Nursing Assessment (cont’d)
Wellness models
Nonnursing models
Body systems model
Maslow’s Hierarchy of Needs
Developmental theories

49. Validating Data Assessment complete
Validation -determining that objective and related subjective data agree
Clarify vague statements
Double-check extreme data; use references as needed

50. Validating Data (cont’d)
Determine which data can be overlooked
Differentiate between cues and inferences
Avoid jumping to conclusions

51. Documenting the Assessment
Record client data
Record in factual manner; do not state interpretations
Record subjective data with quotes in client’s own words