1. Health Assessment & the Nurse

(1/23/24) lecture by sir james d. lim

assessment

• A deliberate and systematic form of data collection to determine client's current and past health status, functional status and to determine client's present and coping patterns.

• purpose: to formulate nursing problems/diagnosis

nursing process

• a continuous process of systematic problem-solving method and rational planning method

  • assessment

    • most important step that sets the tone for the rest of the process

    • method to help establish baseline

  • diagnosis

  • planning

    • setting goals and outcomes

  • implementation

  • evaluation

types of assessment

• comprehensive

  • thorough and detailed health history & physical examination

  • examines patient's overall health status

  • time-consuming

• focused

  • problem-oriented

  • perform on an on-going basis to monitor and evaluate patient's progress, intervention, and response to treatment

assessment skills

• interpersonal/affective skills

  • assessment is a "feeling" process.

    • affective skills are needed to develop caring, therapeutic nurse-patient relationships

    • the quality of assessment depends on the relationship you developed with your patient.

    • establishing trust and mutual respect is essential before you begin the assessment.

• cognitive skills

  • assessment is a "thinking process"

    • critical thinking is reflective, reasonable thinking. It is not just doing, it is asking "why?"; it involves inquiry, interpretation, analysis, and synthesis.

    • a scientific method of problem solving.

    • needed in clinical decision making.

• psychomotor skills

  • skills needed to perform the four techniques of physical assessment. Most important skill

    • inspection

    • palpation

    • percussion

    • auscultation

• ethical skills

  • assessment is being responsible and accountable.

    • patient advocate

    • respect patients' rights

    • assure confidentiality

communication

-a process of sharing information and meaning, of sending and receiving messages.

• verbal

• nonverbal

  • vocal cues

    • quality of voice

    • tone, intensity

    • speed

  • action/kinetic cues

    • body movements

    • posture, arm position

    • hand gestures

    • facial expression, eye contact

  • object cues

    • your appearance is equally important

    • grooming and dress should be appropriate for the situation

communication techniques

• affirmation

  • acknowledges patient's responses.

• silence

  • allow patient to collect his thoughts.

• restating

  • helps clarify and validate what the patient has said.

• active listening

  • conveys interest and acceptance.

• broad & general openings

  • effective when you want to hear what is important to your patient.

  • use open-ended questions.

how you communicate

• genuineness

  • be open, honest, and sincere with your patient.

• respect

  • everyone should be respected as a person of worth and value.

• empathy

  • knowing what your patient means and understanding how she or he feels.

personal space

• the territory surrounding a person that he perceives as private or the physical distance that needs to be maintained for the person to feel comfortable.

• defined by culture and situation

four distinct zones

• intimate (0-2 ft)

• personal (2-4 ft)

• social (4-12 ft)

• public (more than 12 ft)

touch

• person's response to touch depends on trust formed within a relationship.

• conveys feelings, such as anger and care.

a. data collection

• subjective

  • covert, not measurable

  • referred to as “symptoms”

    • thoughts

    • beliefs

    • feelings

    • sensation

    • perception

• objective

  • overt, measurable

  • referred to as "signs"

    • physical exam

    • diagnostic studies

sources of data

• primary data source

  • patient

• secondary data source

  • family members

  • friends

  • other health providers

  • old medical records

methods of data collection

1. interview

2. observation

3. physical assessment

interview

• types:

  • directive

    • structured with specific questions and controlled by the nurse.

    • require less time, very effective for obtaining factual data.

  • non-directive

    • controlled by the patient.

    • very effective at eliciting patient's perceptions and feelings.

    • require more time.

• phases of the interview:

  • introductory phase

    • introduces self

    • explains the purpose of interview

    • explains time frame

  • working phase

    • data collection phase

    • longest phase

  • termination phase

    • end of interview

    • summarize & restate findings

observation

• uses all of your senses

• examines the patient and environment

physical assessment

• inspection

  • involves looking at your patient and compare her or his appearance with what you know as normal.

• palpation

  • examining with the hands, feeling for organs and masses.

    • light

      • use to assess surface characteristics (1")

    • deep

      • assess organs and masses (2-3")

• percussion

  • tapping a body surface area to determine the density of a part by the sound it produce.

  • elicits area of tenderness

    • rebound tenderness- a clinical sign in which there is pain upon removal of pressure rather than application of pressure to the abdomen.

• auscultation

  • listening to the sounds made by various body structures through a stethoscope.

b. validating data

• compare subjective and objective data.

• ask patient to validate assessment data.

• use other sources to validate data

  • family members

  • healthcare providers

  • old records

  • diagnostic tests

c. organizing/clustering data

• methods:

  • Maslow's Hierarchy of Needs

  • Roy's Adaptation Theory

  • Gordon's Functional Health Patterns

d. prioritizing data

• primary or top priority

  • life-threatening problems

    • Airway

    • Breathing

    • Circulation

• secondary

  • problems affecting basic needs requiring prompt attention to prevent deterioration in patient's condition

    • pain

• tertiary

  • problems affecting psychosocial needs

    • anxiety

    • fear

    • loneliness

documenting data methods

• SOAPIE

  • subjective data

  • objective data

  • assessment/clinical judgment

  • plan

  • interventions

  • evaluation

• DAR

  • data

  • action

  • response

• PIE

• Narrative

documentation tips

• be brief and to the point.

• use acceptable abbreviations.

• if documentation is handwritten, make sure writing is legible.

• no need to write in complete sentences.

• state the facts. Avoid interpretations.

• avoid terms such as "normal," "good," "usual," and "average”.

• avoid generalizations.

• document sequentially, in chronological order.

• do not leave blanks or skip lines.

• use correct spelling and grammar.

• no erasures or whiting out.

• record date and time and sign your full signature