MODULE 2 NURSING ASSESSMENT

ASSESMENT

ASSESMENT

collecting, organizing, validating and documenting data in order to establish a database about the client’s response to health concerns or illness and the ability to manage healthcare.

DIAGNOSIS

analyzing and synthesizing data in order to identify client strengths as well as health problems that can be prevented or resolved by collaborative and independent nursing interventions and to develop a list of nursing and collaborative problems

PLANNING

determining how to :

• prevent, reduce or resolve the identified priority client problems

• Support client’s strength

• Implement nursing interventions in an organized individualized and goal-directed  manner in order to  develop and individualized care plan

IMPLEMENTATION

Includes:

• Carrying out or delegating and documenting the planned nursing interventions in order to assist the client to meet desired goals/outcomes

• Promote wellness

• Prevent illness and disease

• Restore health

• Facilitate coping with altered functioning

EVALUATION

Includes measuring the degree to which goals/outcome have been achieved and identifying factors that positively or negatively influence goal achievement in order to determine whether to continue, modify or terminate the plan of care

Purpose of Assessment

Establish database about the client’s response to health concerns or illness and the ability to manage health care needs and is a continuous process carried out during all phase of the nursing process.

INITIAL ASSESSMENT

• Performed with specified time after admission to a health care agency

• To establish complete database for problem identification, reference and future comparison

• e.g. nursing admission assessment

PROBLEM-FOCUSED ASSESSMENT

• Ongoing process integrated with nursing care

• To determine the status of a specific problem identified in an earlier assessment

• e.g. hourly assessment of client’s fluid intake and urinary output in an ICU

EMERGENCY ASSESSMENT

• During any physiological or psychological crisis of the client

• To identify life-threatening problems

• To identify new or overlooked problems

• e.g. rapid assessment of an individual’s airway, breathing status and circulation during cardiac arrest, assessment of suicidal tendencies or potential for violence

TIME-LAPSED ASSESSMENT

• Several months after initial assessment

• To compare the client’s current status to baseline date previously obtained

• e.g. reassessment of a clint’s functional health patterns in a home care or outpatient setting of in a hospital at shift change

SUBECTIVE DATA

• Referred to as symptoms

• Covert data

• Apparent and can be described only by the client

• Sensation, feeling, values, beliefs, attitude and perception of personal health status and life situation

OBECTIVE DATA

• Referred to as signs

• Overt data

• Detectable by observer or can be measured or tested against an accepted standard.

• Can be seen, heard, felt, or smelled and are obtained through observation or physical examination

PRIMARY SOURCE

Data that comes from the client

SECONDARY SOURCE

• The client’s parent/company during the assessment

• All can be considered secondary or indirect data as long as it does not came from the client

OBSERVING

• Gathering data by using the senses, although nurses mostly observe through sight and most senses are engaged during careful observation.

• Useful for gathering data such as skin color or lesions, body or breath odors, lung or heart sounds and skin temperature

INTERVIEWING

• Planned communication or a conversation with a purpose.

• Useful to identify problems of mutual concern, evaluate change, teach, provide support or provide counseling or therapy

EXAMINING

• Reffered to as physical examination or physical assessment

• Systematic data collection method that uses observation ; 5 senses and nursing techniques ( inspection, palpation, percussion and auscultation)

• Useful for assessing all body parts and comparing findings on each side of the body

DIRECTIVE INTERVIEW

• highly structured and elicits specific information.

• Nurse establishes the purpose and control the interview ; usually used when the time is limited

NON DIRECTIVE

• rapport-building interview, the nurse allows the client to control the purpose, subject matter and pacing

• combination of this together with directive is usually appropriate during the information- gathering interview

CLOSED ENDED QUESTIONS

• Restrictive and generally require only “yes” or “no” answers

• Could also be short factual answer giving specific information

• Often begin with “when”, “where”, “who”, “what”, “do” or “is”

OPEN ENDED QUESTIONS

• Invite the clients to discover, explore, elaborate, clarify, or illustrate their thoughts or feelings

• Specifies only broad topic to be discussed

• invites answers longer than one or two or words

• Gives the client the freedom to divulge only the information that they are ready to disclose

• often begin with “what” or “how”

Thing to consider for an health Interview

• setting

• time

• place

• seating arrangement

• distance

• language

Validation of Data

Done by double checking information and differentiating between cues and inferences

Documentation

• Helpful tool after collecting, organizing, and validating data.

• the nurse record the client’s data.