Comprehensive Nursing Process & Assessment Techniques

Nursing Process

-Assessment

-Diagnosis

-Planning

-Implementation

-Evaluation

Assess

gather information about pt condition

Diagnose

identify the clients problems

Plan

set goals of care & desired outcomes

Implement

perform the nursing actions identified in planning

Evaluate

determine if goals met outcomes

Framework of Health Assessment in Nursing

-history of present health concern

-personal history

-family history

-lifestyle & health practices

Types of Health Assessments

-Initial comprehensive

-Ongoing or partial

-Focused or problem-oriented

-Emergency

Collecting Subjective Data

-biographical information

-history of present health concern

-personal health history

-family history

-health & lifestyle practices

-review of systems

Collecting Objective Data

PHYSICAL

-body functions

-appearance-general survey

-behavior

-measurements

-results of lab tests

Validation of Data

-differences between sub and obj data

-differences between what the pt says at one time vs another

-findings that are abnormal or inconsistent w/ other findings

Phases of Collecting Subjective Data

-Pre Introductory Phase

-Introductory Phase

-Working Phase

-Summary & Closing Phase

Verbal Communication

-tone of voice

-pace & clarity

-word choice

-active listening

Non-Verbal Communications

-facial expressions

-eye contact

-body & posture orientation

-gestures

-proxemics

-touch

How to Defuse Emotional Situation

-stay calm yourself

-use nonthreatening body language

-show empathy

-validate feelings before problem-solving

- offer choices when possible

Best Type of Questions to ask Patient

-open ended questions

-probing questions

-clarifying questions

-close ended questions

-empathy evoking questions

Complete Health History

-biographical data

-reasons for seeking health care

-history of present heat concern

-past health history

-family history

-lifestyle & health practices

-development level

-review of systems

COLDSPA

-character

-onset

-location

-duration

-severity

-pattern

-associated factors

PQRST

-provocations

-quality

-region

-severity

-time

General Survey

-physical assessment & body build

-sex @ birth, gender identity

-skin condition & color

-dress & hygiene

-posture & gait

-level of consciousness

-behaviors

-speech

-vital signs

-facial expression

Pulse

0-Absent

1-weak, diminished (easy to obliterate)

2+ normal (obliterate w moderate pressure)

3+strong (obliterate w firm pressure)

4+ bounding (unable to obliterate)

What can affect BP?

-caffeine

-excerise

-pain

-temp

-time of day

-emotions

-sitting & standing

When should hand hygiene be performed?

-Before and after patient care

Respiratory Hygiene

cough into arm and/or cough/sneeze into tissue

What position should the client be in a physical examination?

Sitting up (Fowlers Position) this allows access to the upper exteremties

What do we palpate for?

-texture

-temp

-moisture

-mobility

-consistency

-strength

-sizes

-tenderness

What parts of the hands are used for palpation?

finger pads, ulnar/palmar surface, dorsal surface

Percussion

involves tapping body parts to produce sound waves

What do we percuss for?

-eliciting pain

-determining location, size, shape

-determining density

-detecting abnormal masses

-eliciting reflexes

Auscultation

-used for listening to heart sounds

-movement of blood

-bowel movement

-movement of air through --respiratory system

Dos and Don'ts

-do not auscultation through clients clothes

-warm bell for 10 sec

-listen for low pitched sounds, too loud, blowing, or murmurs, or bruits abnormalities

Steps to Make a Clinical Judgement

1.Identify abnormal cues & supportive cues

2. Cluster Cues

3. Draw inference to hypothesize

4.Identify client concerns

5. validate the client concern w/ family and/or loved ones

6.Document clinical judgement

Pitfalls

2 sets:

-those that occur during assessment phase & those that occur during the analysis phase

Pitfall during Assessment Phase

-too many or inadequate data, unreliable, or invalid data, & insufficient number of cues available

Pitfall during Analysis Phase

cues may be clustered yet unrelated to each other or making clinical judgement w/o hypothesizing several possibilities

-be careful of wording to not confuse other care team members

-do not overlook cultural background

Temperature

most core: rectal

used for children: axillary

wait minutes before taking oral temp

elderly folks may have lower body temp due skin loss & muscle loss

What is another factor that affects BP?

-Cardiac output

-Elasticity of the arteries

-Blood volume

-Blood velocity (heart rate)

Blood viscosity(thickness)

Ideal cuff should be?

-bladder length 80%

-40% of the arm circumference

Physiologic Responses to Pain

-increased HR

-increased RR

-decreased urinary output

-sleeplessness

-dilated pupils

Types of Pain

-psychological

-psychogenic/psychosomatic

-neuropathic

-inflammatory pain

-somatic

-visceral

-referred

-phantom

-cancer

-radicular

Most common type of pain

is in older adults: joint pain, back pain, & neck pain

How to asses pain in older adults?

Assess:

-facial expressions

-change in body language

-change in vital signs(HR&BP)

-behavioral change (refusing to eat, change in usual patterns)

-physical change(crying, pressure areas)

What other factor can affect pain?

Socioeconomic Factors:

Education

Financial stability

Housing etc

How to assess pain those who are intubated, infants, older adults w/ dementia?

-facial expressions

-upper limbs(partially bent, retracted, grimacing)

-compliance with ventilation

Infant pain

FLACC:

-Face

-Legs

-Activity

-Cry

-Consolability

Nociceptors

transmits sensation to the central nervous system

Transduction

pain begins when a mechanical, thermal, or chemical stimulus, results in tissue injury or damage to nociceptors

A delta primary afferent fibers

transmit fast pain to the spinal cord within 0.1sec which is felt as sharp, pricking, or electric quality sensation caused by mechanical factors or thermal

C fibers

transmit slow pain within 1 sec, felt as burning, throbbing, or aching caused mechanical, thermal, or chemical stimuli

Transmission

initiated by inflammatory process

Perception

emotional status affects level of pain

Conditioned Pain Modulation

one area of the body is decreased when another painful stimulus is applied to a different area

Psychological Pian

living with chronic pain has been linked to increases in depression, stress, headaches, 7 even suicide

Psychosomatic Pain

transferring uncomfortable feelings into physical symptoms

Nociceptive Pain

most common type of pain

-nerve receptors detecting harmful stimuli reacting to mechanical, chemical, or thermal stimuli

Neuropathic Pain

results from any damage to the nervous system

Inflammatory Pain

increased sensitivity of perception & emotional response

Somatic Pain

damage to musculoskeletal system, soft tissues, bones, muscles, skin, & mucus membranes

Radicular Pain

root at its connection to the spinal nerves

Referred Pain

pain in a body region distant from the actual source

Phantom Pain

sensation of feeling pain in a part of the body that has been removed

Cancer Pain

-pain is related to tumors pressure on nerves, bones or body organs

-cancer treatments cause their own pain

Psychosocial Factors Affecting Pain Perception & Assessment

development level, age, & culture

Nutrition

process by which substances in food are transformed into tissues & provide energy for the full range of energy

Malnutrition

over nutrition & undernutrition

Undernutrition

inadequate nutrient intake

Risk factors of undernutrition

-lower SES

-lifestyle of long work hours

-poor food choices

-chronic dieting

-dental issues

-unable to cook for self

-disorders

Over nutrition

occurs when the intake of nutrients exceeds the metabolic needs for the body to maintain

What can over nutrition lead to?

obesity, type 2 diabetes, cancer, gallbladder, hypertension, cardiovascular

What can adequate hydration be affected by?

-high fevers

-high intake of alcohol

-in ability to access fluids

-high environmental temp

-people taking diuretic medications

Optimal Hydration

maintains the hydration of all body systems & organs

Healthy People 2030 Goal

reduce overweight & obesity by helping people eat healthy & get physical activity

Risk Assessment for Obesity

-Genetics

-Family activity level

-Inactivity

-Smoking

-Lack of sleep

-Pregnancy

over hydration

pt at risk for this are those w/ kidney, liver, & cardiac diseases

Food intolerance

irritation or when the digestive system is unable to break down to break down or properly digest food

Food interactions

issues w/ food interacting with meds

Diets

-clients with constipation issues should eat high fiber diets 7 drink enough water

-heart healthy-low sodium diets

ISBAR

-Introduction

-Situation

-Background

-Assessments

-Recommendation

Collecting Objective Data

-Inspection

-Auscultation

-Percussion

-Palpate

Standard Precaution

-Hand hygiene

-Gown

-Don

-Gloves