Patient Assessment (The First Step of Nursing Process)

Identifying a Framework for Care: The Nursing Process

A systematic framework used to identify a patient’s health care needs, determine priorities of care goals and expected outcomes, and establish a nursing plan of care to meet these patient-centered needs.

Five interrelated steps (The nursing process):

1. Assessment (covered here)

2. Diagnosis

3. Plan

4. Intervention/Implementation

5. Evaluation/Reassessment

Assessment

• General Health Assessment

• Physical: Inspection, palpation, percussion, auscultation, review of diagnostic data

• Psychosocial (Emotional)

• Cultural

• Spiritual

Patient Assessment in Detail

• All contained in Washington Chapter 3:

• Patient Assessment

• Please review all tables, boxes and charts!

Patient Information from systematic assessment allows the health care provider to:

1. Determine the problem

2. Select an Intervention

3. Evaluate the effectiveness of the intervention

Establishing a Therapeutic Relationship

Communication:

• Verbal

• Non-verbal

• Helpful

• Non-Helpful

• Reflective Listening

The Multidisciplinary Approach to the Assessment of Cancer Patients

General Health Assessment

Physical Assessment includes:

• Nutrition

• Pain

  • Biochemical Balance (Blood counts)

Nutritional Assessment

• Anorexia

• Cachexia

• Protein-caloric malnutrition

  • Marasmus

  • Kwashiorkor

• All pain is real – most feared consequence of CA

• Combination of physiologic and psychogenic factors:

• SIX dimensions to assess and manage the experience of cancer pain:

1. Physiologic: organic cause of pain

2. Sensory: intensity, location and quality

3. Affective: depression and anxiety

4. Sociocultural: effects of cultural, social and demographic factors that deal with the experience of pain – cultural background and family dynamics

5. Behavioral: pain-related behaviors such as medication intake and activity level (Karnofsky Performance Status)

6. Cognitive: the manner in which pain influences a person’s thought processes and the way people view themselves of the meaning of pain

• Blood Assessment

• Biochemical Balance:

  • Blood \ Hematologic Changes

• Myelosuppression: reduction in bone marrow function.

  • These may occurs as a result:

    • Anemia

    • Leukopenia

    • Thrombocytopenia

• Quality of Life Assessment (Psychosocial Assessment)

• Quality of Life Index (QLI), Functional Living Index – Cancer (FLIC)–

• Functional Assessment of Cancer Therapy Scales (FACT & FACT-G), Coping Strategies and Responses – Patient •

  • Anxiety –

    • State-Trait Anxiety Inventory (STAI): –

    • Coping strategies: Wash pg 52, box 13.8 •

  • Depression –

    • Beck Depression Inventory (BDI)

• Coping Strategies and Responses – Family • Family Functioning Index (FFI)–

• Rehabilitation

  • Four Objectives are:

1. Psychological support

2. Optimal physical functioning

3. Early vocational counseling

4. Optimal social functioning

Cultural Assessment

The systematic appraisal of the cultural beliefs, values and practices of individual and communities.

Spiritual Assessment

• Holistic assessment

• A person’s need to find answers

• Spiritual Support brings comfort

• Hope

Special Cases In Assessment

• Children - Pediatrics

  • Assessment of child’s primary caregivers

  • Multi-dimensional task–

  • Determine the developmental level of child

• Adolescents

  • Self-esteem issues

• Elderly

  • Sensory and cognitive impairment that may be present

• Lesbian, Gay, Bisexual, Transgender

  • Demonstrate Care and Consideration

• Palliative and End of Life

Karnofsky Performance Scale