Study Guide - Chapter 15

Assessing

What is an assessment?

Systematic and continuous collection, analysis, validation, and communication of pt data

What is data?

Reflects how health functioning is enhanced by health promotion OR compromised by illness/injury

What are the 5 types of nursing assessments?

1 - comprehensive/initial

2 - focused

3 - emergency

4 - time lapsed

5 - physical assessments

Explain the comprehensive/initial nursing assessment

Baseline; collects data on all aspects of pt health

Performed shortly after admittance to hospital

Explain physical assessment

Head-to-toe assessment that includes inspection, palpation, percussion, and auscultation

Collects objective data

Explain focused assessment

Gathers data on specific problem that was already identified

Often uses COLDSPA

Explain emergency assessment

Performed when physiologic or psychological crisis is happening

Uses ABC

Explain time-lapsed assessment

Compares a pt’s current status to baseline data obtained earlier // reassess health status and makes revisions as needed

What is the difference between nursing assessments and medical assessments?

Nursing assessments focus on pt’s responses to health problems

Medical assessments focus on targeting data pointing to pathology

Explain objective vs subjective assessments

Objective - observable, measurable data that is collected from healthcare worker

Subjective - data collected from what pt says/feels/experiences

What is a database?

Includes all pt information collected by nurse and other healthcare workers

Why is a database important?

Enables the nurse to partner with pts to develop comprehensive + effective care plan

How do we establish priorities for assessments?

Maslow’s hiearchy of needs, ABC’s

Also - health orientation, developmental stage, culture, need for nursing

Describe the methods of data collection

Patient interviews, observation, physical assessments

What are some problems related to data collection?

• Inappropriate organization of database

• Omission of data

• Irrelevant, duplicate, or erroneous data

• Failure to establish rapport

• Recording interpretation of data rather than observed behavior

• Failure to update database

How can we overcome problems related to data collection?

Validation, appropriate documentation of data, confidentiality