CHAPTER 1 NURSES ROLE IN HEALT ASSESSMENT (COLLECTING AND ANALYZING DATA)

nursing process

systematic, rational method of planning and providing individualize nursing care

assessment, diagnosis, planning, implementation, evaluation

5 components of nursing process

assssment

most critical phase of the nursing process

collect data, organize data, validate data, document data

diagnosing

analyze data identify health problems, risk and strengths, formulate diagnostic statements

planning

determining how to prevent, reduce, or resolve the identified priority client problems

implementation

carrying out (or delegating) and documenting the planned nursing interventions

evaluation

measuring the degree to which goals/outcomes

initial assessment, problem-focused assessment, emergency assessment (abc) time-lapsed assessment ongoing

types of assessment

initial assessment

performed within specified time after admission

to establish a complete baseline data

problem-focused assessment

ongoing process integrated with nursing care

to determine the status of specific problem identified at the initial assessment

emergency assessment (abc)

during any life threatening conditions

to identify life threatening problems

time-lapsed assessment ongoing

several months after initial assessment

to compare the client`s current status to previously obtained data

collection of subjective data, collection of objective data, validation of data, documentation of data

steps of health assessment

collection of subjective data

information only the client can report

collection of objective data

data directly observed or measured by the nurse or examiner

inspection, palpation, percussion, auscultation

methods of collection of objective data

validation of data

ensure completeness and accuracy of collected data

documentation of data

forms the foundation of the nursing process

nursing diagnosis, collaborative problem, referral need

analysis of assessment data

nursing diagnosis

defined by nanda: clinical judgement about responses to actual/potential health problems

guides selection of nursing interventions

collaborative problem

physiological complications monitored by nurses

managed with both physician and nurse

referral need

issues requiring other healthcare professionals

actual diagnosis, risk diagnosis, health promotion

types of nursing diagnosis

actual diagnosis

an existing health problem

risk diagnosis

susceptibility to potential infection/risk

health promotion

client is ready to improve wellness

1901-1938

AJN documents nurses using inspection, palpation, auscultation

1930s

public health nurses performed home inspections & disease prevention (red cross, frontier nursing service)

1950s-60s

nurses conducted pre employment exams

1970s

nurses involved in primary health care

expanded roles in physical& psychological assessment

1980s

use or primary care method

nurses made autonomous assessments and developed care plans

1990s

rise of critical pathways/care maps

focus on protocol-based assessments

critical care outreach

assess unstable clients outside icu

ambulatory care

screen clients determine referrals

home health

make independent diagnoses

public health

assess community needs

school nurses

monitor child health & growth

hospice care

assess needs of terminally ill & families