Jensen Chapter 1: The Nurse's Role in Health Assessment

The purpose of the nurse performing the health assessment is to discover symptoms that support the medical diagnosis. T/F

F

The type of assessment used during a life-threatening situation is the focused assessment. T/F

F

_____________-based nursing provides individualized nursing care from best research and scientific findings.

Evidence

Organizing frameworks for assessment include functional, head-to-toe, and ___________ systems.

body

The nursing process consists of three parts: assessment, planning, and evaluation. T/F

F

Five nursing values are used by the nurse to guide professional roles. T/F

T

According to the American Nurses Association, the professional nurse's role involves four broad areas that define nursing practice. T/F

T

Diagnostic reasoning is a seven-step process of _____________ thinking; the nurse gathers and clusters data, draws inferences, and develops nursing diagnoses.

Critical

Health assessment is the first step of the nursing process and includes the health assessment, which is _______________ data, and the physical assessment, which is objective data.

Subjective

The U.S. Department of Health and Human Services has developed a national model for health promotion and ___________ reduction strategies called Healthy People.

Risk

ADPIE

Assessment

Diagnosis

Planning

Implementation

Evaluation

A,B,C,D,E

Airway

Breathing

Circulation

Disability

Exposure

A client is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the client?

Airway

A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing?

A. Initial comprehensive

B. Ongoing or partial

C. Focused or problem-Oriented

D. Emergency

B. Ongoing or partial

A home health nurse is visiting a client who recently was hospitalized for repair of a fractured hip. The client tells the nurse, "I have had a lot of pain in my abdomen." What type of assessment would the nurse conduct?

A. Focused

B. Comprehensive

C. Emergency

D. Ongoing or Partial

A. Focused

A new order for an antibiotic is received for a client. The nurse reviews the client's electronic medical record. The record states the client has no known allergies. What action should the nurse take?

A. Hold the medication

B. Double-check in the admission notes for allergies

C. Administer the medication

D. Ask the client if they have allergies

D. Ask the client if they have allergies

A nurse on the subacute medical unit is planning to perform a client's focused assessment. Which of the following statements should inform the nurse's practice?

A. The focused assessment addresses a particular client problem

B. The focused assessment replaces the comprehensive database

C. The focused assessment is done after gathering subjective data

D. The focused assessment should be done before the physical exam

A. The focused assessment addresses a particular client problem.

The nurse is reviewing a client's health history and physical examination. Which of the following would the nurse identify as subjective data? Select all that apply.

"My father died of a heart attack"

"I feel so tired sometimes"

Client complains of a headache

Pupils equal, round, and reactive to light

Weight - 145 lb

Lungs clear to auscultation

"My father died of a heart attack"

"I feel so tired sometimes"

Client complains of a headache

During a health assessment, the nurse learns that an adolescent is sexually active. What information can the nurse provide the client in order to support the Healthy People 2030 indicator of responsible sexual behavior?

A. The importance of using a condom when engaging in sexual activity

B. The need for frequent diagnostic testing for sexually transmitted infections

C. The need to reduce the percentage of adolescents who are HIV positive

D. The importance of abstaining for sexual activity unless in a monogamous relationship

A. The importance of using a condom when engaging in sexual activity

A client returns to the unit after a thyroidectomy. On entering the client's room, the nurse observes the client having difficulty breathing due to swelling in the neck. What type of assessment should the nurse perform at this time?

ongoing or partial

emergency

comprehensive

focused

Emergency

After completing a health history and physical assessment the nurse prepared to analyze the collected data. In which phase of the nursing process is the nurse focusing?

Nursing diagnosis

Implementation

Evaluation

Planning

Nursing diagnosis

A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment?

Palpation

Empathy

Sympathy

Inspection

Empathy

A nurse conducts an initial comprehensive assessment for a client admitted with a fever of unknown origin. Which area of assessment is primarily the nurse's responsibility?

Collect subjective data related to overall function

Perform a musculoskeletal examination

Take anthropometric measurements

Obtain a 24-hour diet recall

Collect subjective data related to overall function

A nurse recognizes that a thorough and accurate assessment of a client is important to prevent what error from occurring when utilizing the nursing process?

Interjection of the nurse's thoughts or feelings into the data

Validating information that is already correct

Relying on objective and subjective information

Making incorrect nursing judgments or diagnoses

Making incorrect nursing judgments or diagnoses

The nurse is providing care to a newly admitted client with a long history of chronic obstructive pulmonary disease (COPD). According to the client's chart, the client has been taking several inhalers to manage their respiratory condition. The nurse enters the room with the prescribed inhalers to administer them. What action should the nurse take next?

Ask the client if they need any assistance with the inhalers.

Leave the inhalers with the client to self-administer.

Validate that the client understands how to use the inhalers.

Provide privacy for the client to administer the inhalers.

Validate that the client understands how to use the inhalers

Revising the plan as needed occurs in what part of the nursing process?

Assessment

Diagnosis

Planning

Evaluation

Evaluation

The nurse is completing an assessment on a new client at the community health clinic and would like to screen the client’s cognitive ability. There are many resources that provide screening tools for nurses. Which agency would be most helpful in directing the nurse to a screening tool to assess the client’s cognitive ability?

the American Ophthalmology Association (AAO)

the Alzheimer’s Association (AA)

the American Diabetic Association (ADA)

the American Heart Association (AHA)

the Alzheimer's Association (AA)

A client admitted with a small bowel obstruction requires a nasogastric tube to continuous low wall suction. The nurse monitors gastric output of 250 mL at 0800–0900 and 30 mL at 0900– 1000. The nurse understands that drainage should taper and not decrease abruptly within an hour. What is the best action of the nurse?

Intervene by pulling out the nasogastric tube.

Assess the nasogastric tube for proper functioning.

Develop a plan of care.

Evaluate output in an hour.

Assess the nasogastric tube for proper functioning.

A community health nurse is assessing an older adult client in their home. When the nurse is gathering subjective data, which of the following would the nurse identify?

The client's behavior

The client's feelings of happiness

The client's posture

The client's affect

The client's feelings of happiness

An instructor is describing a comprehensive nursing health assessment to a group of students. The instructor determines that the teaching was successful when the students identify which of the following as the overall purpose?

Collect large quantities of data

Validate previous data

Assist the physician

Make a clinical judgment

Make a clinical judgment

Total parenteral nutrition (TPN) has been prescribed for a client. After several hours of infusion, the nurse checks the client's glucose and it is elevated, requiring insulin. The nurse administers the insulin as prescribed. What step in the nursing process should the nurse take next?

diagnosis

evaluation

planning

assessment

Evaluation

The nurse recognizes the goals and objectives of the Healthy People 2030 guidelines when creating a plan of care that addresses which client-centered goal(s)? Select all that apply.

living a healthy lifestyle

disease prevention

improving one's quality of life

providing affordable health care services

increasing the longevity of one's life

living a healthy lifestyle

disease prevention

improving one's quality of life

increasing the longevity of one's life

What are the four broad/main goals in nursing?

i. To promote health

ii. To prevent illness

iii. To treat human responses to health or illness

iv. To advocate for individuals, families, communities, and populations

Autonomy

agreement to respect another's right to self-determine a course of action; support of independent decision making.

Beneficence

compassion; taking positive action to help others; desire to do good; core principle of our patient advocacy.

Fidelity

loyalty, fairness, truthfulness, advocacy, and dedication to our patients. It involves an agreement to keep our promises. Fidelity refers to the concept of keeping a commitment and is based upon the virtue of caring

Veracity

conformity to facts; accuracy; truth telling

Justice

an equal and fair distribution of resources, based on analysis of benefits and burdens of decision. Justice implies that all citizens have an equal right to the goods distributed, regardless of what they have contributed or who they are.

Non-maleficence

avoidance of harm or hurt; core of medical oath and nursing ethics.

Core nursing values are

i. Respect

ii. Unity

iii. Diversity

iv. Integrity

v. Excellence

Primary prevention

Preventing problems

Secondary prevention

Early diagnosis and prompt treatment; reduce complications

Tertiary prevention

Prevent complications of existing disease

Primary prevention involves

strategies aimed at preventing problems.

Immunizations, health teaching, safety precautions, and nutrition counseling are examples.

Secondary prevention

includes the early diagnosis of health problems and prompts treatment to prevent complications; Vision screening, Pap smears, BP screening, hearing testing, scoliosis screening, and tuberculin skin testing are examples.

Tertiary prevention

focuses on preventing complications of an existing disease and promoting health to the highest level. Diet teaching and exercise programs are examples

What is health assessment and what are the purposes for health assessment? What does a health assessment include?

All future care is based on the health assessment, so it is extremely important that health assessment data are complete and accurate. This is one of the most important skills that you will use as a nurse.

Assessment, Diagnosis, Outcome Identification, Planning, Implementation, Evaluation

What is the nursing process nemonic?

ADPIE

Assessment

An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well. For example, a nurse's assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient's response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation.

Diagnosis

The nursing diagnosis is the nurse's clinical judgment about the client's response to actual or potential health conditions or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications—for example, respiratory infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the nurse's care plan.

Outcomes / Planning

Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient's care plan so that nurses as well as other health professionals caring for the patient have access to it.

Implementation

Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient's record.

Evaluation

Both the patient's status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.

What is critical thinking?

Critical thinking in nursing (Alfaro-LeFevre, 2017):

entails purposeful, outcome-directed (result-oriented) thinking;

is driven by patient, family, and community needs;

is based on the nursing process, evidence-based thinking, and the scientific method;

requires specific knowledge, skills, and experience;

is guided by professional standards and codes of ethics; and

is constantly reevaluating, self-correcting, and striving to improve.

What is diagnostic reasoning? What are the steps in diagnostic reasoning?

The diagnostic reasoning process is based on critical thinking. Diagnostic reasoning includes gathering and clustering data to draw inferences and propose diagnoses or hypotheses. A seven-step process for diagnostic reasoning can be used in the context of health assessment (Weber & Kelley, 2018):

Identify strengths and abnormal data.

Cluster data.

Draw inferences.

Propose nursing diagnoses.

Check for defining characteristics.

Confirm or remove diagnoses.

Document conclusions.

What are the three common types of nursing assessments?

Emergency Assessment, Comprehensive Assessment, and Focused Assessment

Emergency Assessment

Involves a life threatening or unstable situation, such as a patient who has experienced a critical traumatic injury.

What are your priorities in each type of assessment?

A, B, C, D, E numonic

A, B, C, D, E numonic

A means...

Airway (with cervical spine protection if an injury is suspected)

A, B, C, D, E numonic

B means...

Breathing: rate and depth, use of accessory muscles

A, B, C, D, E numonic

C means...

Circulation: pulse rate and rhythm, skin color

A, B, C, D, E numonic

D means...

Disability: level of consciousness, pupils, movement

A, B, C, D, E numonic

E means...

Exposure

Comprehensive Assessment

Complete Health History and Physical Assessment.

Frequency can vary, once a month, whereas a patient in an acute hospital setting may require an assessment once per shift (Fig. 1.4). Patients in intensive care settings have vital signs and a focused assessment hourly and sometimes even more often. A facility's standard of care prescribes minimum frequency, so it is important for you to identify those standards for the unit and facility in which you are working.

Focused Assessment

Focused on patient's health issue. Occurs in all settings.

Following treatments to monitor their effectiveness. For example, if your patient who is short of breath is given an inhaler, then listen to lung sounds after the treatment to see if there has been an improvement in wheezing.

Periodic Health Assessment

Focuses on the most common screening and prevention services for four age groups: (1) birth to 10 years, (2) 11 to 24 years, (3) 25 to 64 years, and (4) 65 years and older.

Patients are seen more frequently in the youngest years to monitor growth and development and in later years for the treatment of acute and chronic illnesses

What is the order of priority setting in nursing?

1. When prioritizing, you first address any life-threatening situations and then other issues that need immediate attention.

Life-threatening issues always take priority: for example, circulation, airway, and breathing take priority over elevated temperature. Another example of a situation that requires immediate attention is a patient at risk for human violence or suicide. If the patient is stable, then your priority is an issue that is very important to the patient or something on which you are spending a lot of time.

A—Airway (with cervical spine protection if an injury is suspected)

B—Breathing: rate and depth, use of accessory muscles

C—Circulation: pulse rate and rhythm, skin color

D—Disability: level of consciousness, pupils, movementE—Exposure

What is the difference between a health history and a physical exam?

A health assessment includes both a health history and a physical assessment.

The health history includes interviewing to collect the patient's past medical and surgical histories, lifestyle, and current symptoms. A comprehensive health history also includes nutrition, development, mental health, culture, and safety issues. Data that you collect during the physical assessment vary depending on the seriousness of a patient's condition, health history, and current symptoms

What is subjective data?

Information collected from the subject, the patient. Subjective data is based on patient experiences and perceptions. Patients describe the feeling, sensations, or expectations; you then document them as subjective data or put them in quotes. The nurse's role is to gather information to prove the patient's health status and to help determine the cause of the patient's current symptoms.

What is objective data?

The physical assessment follows the history and focused interview and includes objective data, which are measurable. You observe the patient's general appearance; assess vital signs; listen to the heart, lungs, and abdomen; and assess peripheral circulation.

Why is documentation and communication important?

Documentation of both subjective and objective findings is essential to meet legal requirements and also communicate findings to others. Accurate documentation provides a baseline so that changes can be noted between assessments

There are three frameworks for health assessment, what are they?

functional assessment, body systems, and head-to-toe.

When would you use functional assessment?

focuses on functional patterns that all humans share: health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs (Gordon, 1993). Nurses often use the functional patterns to collect subjective data and a head-to-toe approach for the physical assessment.

When would you use health assessment?

to gather subject and objective data, family history, surgical history, medical history, medication history, and psychosocial history. (subjective data)

When would you use perform head-to-toe assessment?

includes all of the body system, and findings will inform the health care professional on the patient's overall condition.