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Chapter 16 Nursing Assessment

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1 Chapter 16 Nursing Assessment
The nursing process is a critical thinking process that professional nurses use to apply the best available evidence to caregiving and to promoting human functions and responses to health and illness. The nursing process is continuous and dynamic, so you may move back and forth among the steps. Nursing assessment helps nurses to form a clear definition of the patient's problems, which in turn provides the foundation for planning and implementing nursing interventions and evaluating the outcomes of care. The nursing process is also a standard of practice, which, when followed correctly, protects nurses against legal problems related to nursing care. Copyright © 2017, Elsevier Inc. All Rights Reserved.

2 Five-Step Nursing Process
The nursing process is central to your ability to provide timely and appropriate care to your patients. It begins with the first step, assessment, the gathering and analysis of information about the patient’s health status. You then make clinical judgments from the assessment to identify the patient’s response to health problems in the form of nursing diagnoses. Once you define appropriate nursing diagnoses, you create a plan of care. Planning includes setting goals and expected outcomes for your care and selecting interventions (nursing and collaborative) individualized to each of the patient’s nursing diagnoses. The next step, implementation, involves performing the planned interventions. After performing interventions, you evaluate the patient’s response and determine whether the interventions were effective. [Shown is Figure 16-1: Five-step nursing process.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

3 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 Assessment has two stages: First, to collect and verify data from the patient (primary source) and from family, health care providers, and medical records (secondary sources) Second, to analyze the data The data will be used to develop the nursing diagnosis, identify collaborative problems, and develop an individualized plan of care. You perform assessment to gather information needed to make an accurate judgment about a patient’s current condition. Experience, knowledge, standards, and attitudes all influence critical thinking in assessment. Critical thinking is a vital part of assessment. While gathering data about a patient, you synthesize relevant knowledge, recall prior clinical experiences, apply critical thinking standards and attitudes, and use professional standards of practice to direct your assessment in a meaningful and purposeful way. Copyright © 2017, Elsevier Inc. All Rights Reserved.

4 Critical Thinking Approach to Assessment (Cont.)
[Shown is Figure 16-2: Critical thinking and the assessment process.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

5 Case Study Ms. Carla Thompkins, a 52-year-old schoolteacher, is being admitted to the medical-surgical unit as a postop patient 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 she is going to receive preliminary occupational and physical therapy to help her adapt to the amputation. [Ask students: At this point, what would they expect to find during a postop assessment of Ms. Thompkins. Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

6 Developing the Nurse-Patient Relationship for 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 Database Start by taking quality time to be with a patient, even if it is for a few minutes. Establishing a nurse-patient therapeutic relationship allows you to know the patient as a person. This relational process mobilizes hope for a patient and nurse; allows for an acceptable interpretation and understanding of the patient’s illness, pain, fear, and anxiety; and helps the patient use support from health care providers. Connecting with a patient by showing interest in his or her problems and concerns helps you collect a relevant database. Research has shown that hearing accounts of patients’ health and illness experiences, watching them, and coming to understand how they typically respond develops a type of knowing that fosters good clinical judgments. Rounding is a vital opportunity to build trust with patients, increasing the likelihood that you will gain more information that will help you identify and communicate their health care problems more accurately and effectively. Copyright © 2017, Elsevier Inc. All Rights Reserved.

7 Types of Assessments Types include
the patient-centered interview during a nursing health history. a physical examination. the periodic assessments you make during rounding or administering care. When you begin assessment, think critically about what to assess for that specific patient in that specific situation. As you are forming your relationship and connecting with the patient, the patient will begin to share information. Determine which questions or measurements are appropriate on the basis of what you initially learn from the patient about his or her health concerns and history, your clinical knowledge, and your experience with other patients. In most cases a patient will reveal information that directs you to conduct a quick screening. You learn to differentiate important data from the total data you collect. A cue is information that you obtain through use of the senses. An inference is your judgment or interpretation of these cues. Always try to interpret cues from the patient to know how in depth to make your assessment. Assessment is dynamic and allows you to freely explore relevant patient problems as you discover them. When you conduct a more comprehensive patient history, there are two approaches to this assessment. Use of a structured database format on the basis of an accepted theoretical framework or practice standard, which provides categories of information for you to assess. Watson and Foster’s model of “The Attending Caring Nurse,” which supports a comprehensive assessment of caring needs and concerns from a patient’s frame of reference. It uses caring theory as a guide for identifying caring needs and assessing the meaning of both subjective and objective concerns. Gordon’s model of 11 functional health patterns offers a holistic framework for assessment of any health problem provides for a comprehensive review of a patient’s health care problems. [Review Box 16-1, Typology of 11 Functional Health Patterns, with students.] Nola Pender’s “Health Promotion Model.” A comprehensive assessment moves from the general to the specific. Typically certain aspects of a situation stand out as most important. You then ask more focused questions on the basis of the patient’s responses and physical signs. The second approach for conducting a comprehensive assessment is problem oriented. You focus on a patient’s presenting situation and begin with problematic areas such as incisional pain or limited understanding of postoperative recovery. You ask the patient follow-up questions to clarify and expand your assessment so you can understand the full nature of the problem. [Review Table 16-1, Example of Problem-Focused Patient Assessment: Pain, with students.] Whatever approach you use to collect data, you cluster cues, make inferences, and identify emerging patterns and potential problem areas. To do this well you critically anticipate, which means that you continuously think about what the data tell you and decide if more data are needed. Remember to always have supporting cues before you make an inference. Your inferences direct you to further questions. Once you ask a patient a question or make an observant on, patterns form, and the information branches to an additional series of questions or observations. Copyright © 2017, Elsevier Inc. All Rights Reserved.

8 Types of Assessments (Cont.)
[Shown is Figure 16-3: Observational overview using cues and forming inferences.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

9 Types of Assessments (Cont.)
[Shown is Figure 16-4: Example of branching logic for selecting assessment questions.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

10 Types of Data Subjective Objective
Patient’s verbal descriptions of their health problems Objective Observations or measurements of a patient’s health status Subjective data often reflect physiological changes, which you further explore through objective review of body systems. Inspecting the condition of a surgical incision or wound, describing an observed behavior, and measuring blood pressure are examples of objective data. Objective data is measured on the basis of an accepted standard such as the Fahrenheit or Celsius measure on a thermometer, inches or centimeters on a measuring tape, or a rating scale (e.g., pain). When you collect objective data, apply critical thinking intellectual standards (e.g., clear, precise, and consistent) so you can correctly interpret your findings. [Review Box 16-2, Evidence-Based Practice: Health Literacy Assessment, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

11 Case Study (Cont.) Yolanda is the student nurse who has been assigned to admit Ms. Thompkins. Yolanda enters Ms. Thompkins’ room, introduces herself, and begins the admission health history and physical assessment. During the assessment, Ms. Thompkins complains of pain at the incision site. [Ask students: Ms. Thompkins’ report of pain is an example of what type of data? Discuss: Subjective data refers to the patient’s verbal description of his or her health problems. Objective data are observations by another person of a patient’s health status.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

12 Sources of Data Patient Family and significant others Health care team
Medical records Other records and the scientific literature Nurse’s experience A patient is usually your best source of information. Patients who are conscious, alert, and able to answer questions without cognitive impairment provide the most accurate information. An older adult may require more time for assessment than someone younger if hearing or cognitive deficits exist. Use short (but not leading) questions, keep your language uncomplicated, and listen to the patient’s perspective carefully. [Review Box 16-3, Focus on Older Adults: Approaches for Gathering an Older-Adult Assessment, with the students.] Family members and significant others are primary sources of information for infants or children, critically ill adults, and patients who are mentally handicapped or have cognitive impairment. In cases of severe illness or emergency situations, families are often the only sources of information for health care providers. The family and significant others are also important secondary sources of information. Not only do they supply information about the patient’s current health status, but they are also able to tell when changes in the patient’s status occurred. You frequently communicate with other health care team members to assess patients. In the acute care setting, the change-of-shift report, bedside rounds, and patient hand-off are ways that nurses from one shift communicate information to nurses on the next shift. Every member of the team is a source of information for identifying and verifying essential information about the patient. The medical record is a source for the patient’s medical history, laboratory and diagnostic test results, current physical findings, and the primary health care provider’s treatment plan. The record is a valuable tool for checking the consistency and similarities of data with your personal observations. Educational, military, and employment records often contain significant health care information (e.g., immunizations). If a patient received services at a community clinic or a different hospital, you need written permission from the patient or guardian to access the record. Reviewing recent nursing, medical, and pharmacological literature about a patient’s illness completes a patient’s assessment database. This review increases your knowledge about a patient’s diagnosed problems, expected symptoms, treatment, prognosis, and established standards of therapeutic practice. Your experiences in caring for patients are a source of data. Through clinical experience you observe other patients’ behaviors and physical signs and symptoms; track trends and recognize clinical changes; and learn the types of questions to ask, choosing the questions that will give the most useful information. Copyright © 2017, Elsevier Inc. All Rights Reserved.

13 The Patient-Centered Interview
Motivational interviewing Effective communication Interview preparation Phases of an interview Orientation and setting an agenda Working phase Termination A patient-centered interview is relationship based and is an organized conversation focused on learning about the well and the sick as they seek care. Motivational interviewing is used often in counseling that allows you to become a helper in the change process. Effective communication requires courtesy, comfort, connection, and confirmation. Before you begin an interview, be prepared. Review a patient’s medical record when information is available and the previous medical or nurse’s note entry. Were problems identified that perhaps need clarification or follow-up? Does the patient’s admitting diagnosis or other diagnoses suggest lines of questions for you to ask? Hand-off information may frame a clinical problem about which you want to learn more. An initial interview involves collecting a nursing health history and gathering information about a patient’s condition. Later interviews assess more about a patient’s presenting situation and discuss specific problem areas. Begin by introducing yourself, your position, explaining the purpose of the interview. Explain why you are collecting data and assure patients that all of the information will be confidential. Ask the patient for his or her list of concerns or problems. The professionalism and competence that you show when interviewing patients strengthens the nurse-patient relationship. In the working phase, ask open-ended questions. Use attentive listening and other therapeutic communication techniques that encourage a patient to tell his or her story. Do not rush a patient. Initial interviews are more extensive. Gather information about a patient’s concerns and then complete all relevant sections of the nursing history. An ongoing interview allows you to update a patient’s status and concerns, focus on changes previously identified, and review new problems. Termination of an interview requires skill. Summarize your discussion with a patient and check for accuracy of the information collected. Give your patient a clue that the interview is coming to an end. End the interview in a friendly manner, telling the patient when you will return to provide care. Copyright © 2017, Elsevier Inc. All Rights Reserved.

14 Interview Techniques Observation Open-ended questions
Leading questions Back channeling Direct closed-ended questions Observe a patient’s nonverbal communication such as use of eye contact, body language, or tone of voice, and determine whether the data you obtained are consistent with what the patient states verbally. If you establish a trusting nurse-patient relationship, the patient feels comfortable asking you questions about the health care environment, planned treatments, diagnostic testing, and available resources. An open-ended question gives a patient discretion about the extent of his or her answer, and does not presuppose a specific answer. They prompt patients to describe a situation in more than one or two words. Leading questions are the most risky because of possibly limiting the information provided to what a patient thinks you want to know. Back channeling includes active listening prompts such as “all right,” “go on,” or “uh-huh.” These indicate that you have heard what a patient says, are interested in hearing the full story, and are encouraging the patient to give more details. Probing encourages a full description without trying to control the direction the story takes, using “Is there anything else you can tell me?” or “What else is bothering you?” Closed-ended questions limit answers to one or two words such as “yes” or “no” or a number or frequency of a symptom. They require short answers and clarify previous information or provide additional information, and do not encourage the patient to volunteer more information than you request. [Ask students: What are some examples of each interview technique? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

15 Nursing Health History
During the patient-centered interview you will learn which components of history to explore [Shown is Figure 16-5: Dimensions for gathering data for a health history.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

16 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. As a professional nurse, it is important to conduct all assessments with cultural competence. Be respectful; understand these differences; and do not impose your own attitudes, biases, and beliefs. Having a genuine curiosity about a patient’s beliefs and values lays a foundation for a trusting patient-nurse relationship. Avoid making stereotypes; draw on knowledge from your assessment, and ask questions in a constructive and probing way to allow you to truly know who the patient is. Do not make assumptions about a patient’s cultural beliefs and behaviors without validation from the patient. [Review Box 16-4, Cultural Aspects of Care: Developing a Patient-Centered Approach, with the students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

17 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. Answer: B Rationale: Assessment is the first stage of the nursing process, and is the process of gathering data to formulate the nursing diagnosis and care plan. Copyright © 2017, Elsevier Inc. All Rights Reserved.

18 Components of the Nursing Health History
Biographical information Patient expectations Reason for seeking health care Present illness or health concerns Health history Family history Psychosocial history Spiritual health Review of systems Nursing health history = Data about the patient’s current level of wellness. When collecting a complete nursing history, let the patient’s story guide you in fully exploring the components related to his or her problems. Biographical information: age, address, occupations, marital status, health care insurance. Chief concern or reason for seeking health care: You learn the patient’s chief concerns or problems. Record the patient’s response in quotations to indicate the subjective response. Clarification of a patient’s perception identifies potential needs for symptom management, education, counseling, or referral to community resources. Patient expectations: Find out what patients expect to happen to them while seeking treatments for their health. Assess whether expectations have been met. If not met, patients consider care as poor. Present illness or heath concerns: Determine when the problems began, how severe, intensity, quality, what makes them worse, and what makes them better. Use PQRST: provokes, quality, radiate, severity, time. Concomitant symptoms: Does the patient experience other symptoms along with the primary symptom? Health history: Provides you with information regarding the patient’s past history. Has there been a hospitalization? A procedure? Medication uses? Prescription, over the counter, herbal, natural? Use of alcohol, tobacco, caffeine, recreational drugs? Sleeping patterns? Exercise habits? Nutritional habits? Family history: Blood relative health issues? Recent losses? Religious influences? Relationships? Allergies? Also, include patient habits and lifestyle patterns. Family history: Data about immediate and blood relatives, which determines risks of a genetic or familial nature. Environmental history: Home environment? Workplace environment? Exposure to pollutants? Psychosocial history: Support system? Spouse? Children? Friends? Family members? Stress coping mechanisms? Spiritual health: Review with patients their beliefs about life, their source for guidance in acting on beliefs, and the relationship they have with family in exercising their faith. Also assess rituals and religious practices that patients use to express their spirituality. Review of systems (ROS): A systematic approach for collecting subjective information from patients about the presence or absence of health-related issues in each body system. During the ROS ask the patient about the normal functioning of each body system and any noted changes. Copyright © 2017, Elsevier Inc. All Rights Reserved. 18

19 Observation of Patient Behavior
It is important to closely observe a patient’s verbal and nonverbal behaviors. Adds depth to objective database Observations direct you to gather additional objective information to form accurate conclusions about the patient’s condition. An important aspect of observation includes a patient’s level of function: the physical, developmental, psychological, and social aspects of everyday living. You learn to determine if data obtained by observation matches what the patient communicates verbally. Observation of level of function differs from observations you make during an interview. You assess level of function by watching what a patient does when eating or making a decision about preparing a medication rather than what the patient tells you that he or she can do. Observation of function often occurs in the home or in a health care setting during a return demonstration. Copyright © 2017, Elsevier Inc. All Rights Reserved.

20 Nursing Health History (Cont.)
Diagnostic and laboratory data Results provide further explanation of alterations or problems identified during the health history and physical examination Interpreting and validating assessment data Ensures collection of complete database Leads to second step of nursing process Compare laboratory data with the established norms for a particular test, age group, and gender. The successful ongoing interpretation and validation of assessment data ensures that you have collected a complete database. Ultimately this leads you to the second step of the nursing process, in which you make clinical decisions in your patient’s care. When critically interpreting assessment information, you determine the presence of abnormal findings, recognize that further observations are needed to clarify information, and begin to identify the patient’s health problems. The patterns of data reveal meaningful and usable clusters. [Review Box 16-5, Recognizing Data Clusters, with the students.] Validation of assessment data is the comparison of data with another source to determine data accuracy. Validate findings from the physical examination and observation of patient behavior by comparing data in the medical record and consulting with other nurses or health care team members. Copyright © 2017, Elsevier Inc. All Rights Reserved.

21 Nursing Health History (Cont.)
Data documentation Use clear, concise appropriate terminology Becomes baseline for care Concept mapping Visual representation that allows you to graphically show the connections among a patient’s many health problems Record the results of the nursing health history and physical examination in a clear, concise manner using appropriate terminology, which becomes the baseline to identify patient health problems, plan and implement care, and evaluate a patient’s response to interventions. When recording data, pay attention to facts and be as descriptive as possible. Anything heard, seen, felt, or smelled should be reported exactly. Record objective information in accurate terminology. Record any subjective information by using quotation marks. Do not generalize or form judgments through written communication when entering data. Conclusions about such data become nursing diagnoses and thus must be factual and accurate. The concept map is a strategy that develops critical thinking skills by helping a learner understand the relationships that exist among patient problems. Concept maps foster reflection and help students evaluate critical thinking patterns and see the reasons for nursing care. Your first step in concept mapping is to organize the assessment data you collect. Placing all of the cues together into the clusters that form patterns leads you to the next step of the nursing process, nursing diagnosis. Through concept mapping you obtain a holistic perspective of your patient’s health care needs, which ultimately leads you to making better clinical decisions. [Review Figure 16-6, Concept map for Mr. Lawson: Assessment, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

22 Case Study (Cont.) Yolanda asks Ms. Thompkins a series of questions about her pain, including: “Describe your pain to me.” “Is the pain worse in the morning or in the evening?” “Place your hand over the area that is uncomfortable.” “Rate your pain on a scale of 0 to 10.” [Ask students: Which of Yolanda’s questions to Ms. Thompkins addresses the nature of Ms. Thompkins’ pain? Discuss: Asking the patient to describe or show the location of pain addresses the nature of pain. Asking the patient about pain during certain periods of the day or in association with movement addresses precipitating factors of pain. Severity of pain is addressed by a pain scale rating.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

23 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. Answer: C Rationale: The interview process is an integral part of patient-centered care, and is continuous throughout patient interaction, regardless of the stage of the nursing process. Copyright © 2017, Elsevier Inc. All Rights Reserved.

24 Case Study (Cont.) Yolanda knows that the best source of information regarding Ms. Thompkins’ care is the surgeon. [Ask students: Is this true? Discuss: The best source of information regarding the patient’s care is typically the patient, as long as the patient is conscious, alert, and able to accurately answer questions.] Copyright © 2017, Elsevier Inc. All Rights Reserved.


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