HEALTH ASSESSMENT MIDTERM

Intro to HA

  • Assessing = determine health problems and care needs of patient
  • More precise = better outcomes

Precise vs Accurate

Accuracy

  • measures how close results are to the true or known value.

Precision

  • measures how close results are to one another

Purpose of the Assessment

  1. To collect data pertinent to the patient’s health status (Subjective/Objective)
  2. To identify deviations from normal
  3. To discover the patient’s strengths, limitations and coping resources
  4. To identify the actual problem
  5. To build rapport with a patient and his/her family.

Purpose of HEALTH ASSESSMENT

  1. To obtain baseline data about the client’s functional abilities.
  2. To supplement, confirm or refute data obtained in nursing history.
  3. To obtain data that will help establish nursing diagnoses and plan of care.
  4. To evaluate the physiological outcome of health care and the progress of the client’s health problem.
  5. To make clinical judgment about a client’s health status.
  6. To identify areas for health promotion and disease prevention.

Skills Required (CPPAE)

  • Cognitive Skills
    • Assessment is a “thinking” process
    • Critical thinking
      • Why? How? What? When?
    • Critical decision-making
      • Use knowledge and experience
  • Problem Solving Skills
    • With scientific methods
    • Experience
    • “Intuition” with experience
  • Psychomotor skills
    • Assessment is “doing”
    • Skills involve physical movements and coordination, which are essential for performing tasks such as administering medication, performing physical assessments, and providing patient care
  • Affective /Interpersonal Skills
    • Assessment is “feeling” trust and mutual respect
  • Ethical skills
    • Assessment is “being responsible and accountable for your practice”

Four Types of Assessment (IFTE)

  1. Initial assessment
    1. Triage
    2. Aids in determining the nature of the problem and lays foundation for the subsequent stages of evaluation
    3. Done within specified time after admission to Hospital
    4. Examples:
      1. Obtain patients medical history
      2. Performing a physical exam
      3. Preparing a psychosocial assessment for a mental health patient.
  2. Focused assessment
    1. The problem is exposed and treated during the focused assessment step.
    2. Purpose;
      1. To determine the status of a specific problem identified in the earlier assessment & identify new or overlooked problems.
        1. Eg. Hrly fluid intake output assessment
    3. Objectives;
      1. Diagnose
      2. Treat

    1. Examples:
      1. Vital signs
      2. Initial pain assessment.
  1. Time-Lapsed Assessment
    1. It may last one or two hours or several months, depending on the severity of the disease.
    2. The present status of the patient is compared to the previous baseline during and prior to therapy.
    3. It may includes:
      1. Blood tests
      2. X-ray
      3. Other diagnostic medical tests.
  2. Emergency Assessment (BLS)
    1. Identifying the patient’s core reasons of concern and monitoring the patient’s airway, breathing and circulation (ABCs)
    2. May become an initial or focused assessment once the ABCs have been stabilized
    3. (start with checking circulation if there is bleeding)

Methods of Assessment (OIE)

  • Observation
    • Systematic collection of data from persons who are getting care in order to inform clinical decision-making
    • Entails taking a person-centered approach to actively connect with patients, their families and nurses
    • Aims to build rapport while also assisting with assessment.
    • 4 senses: vision, hearing, smell and touch
  • Interview
    • Also known as the history, serves as the starting point for all other aspects of the nursing process.
    • Structured in a way that the nurse gains understanding of the patient adaptive process.
    • A planned communication or a conversation with a puepose with two approaches;
      • Directive
        • Focused on leading clients to a solution
      • Non directive
        • Encourage clients to talk and open up
    • Factors
      • Physical setting
      • Nurse's behavior
      • Type of questions asked
      • How questions are asked
      • Personality and behavior of patients
      • How patient is feeling at the time of interview
      • Nature of information being discussed or problem being confronted
    • Health History
      • It is the collection of subjective data that includes information on both the patient's past and present health status.
      • It allows positive aspects of health problems, health teaching needs, and health concerns to be identified.
    • Personal Profile
      • Chief complaint or present illness
      • Past Health History
      • Current medication
      • Personal habits and patterns of living
      • Psychosocial history- Mental status Children and Adolescent

.

  • Examination
    • Four procedures; IPPA
      • Inspection
      • Palpation
      • Percussion
      • Auscultation
    • Abdominal examination; IAPP
      • Inspection
      • Auscultation
      • Percussion
      • Palpation
    • Signs
      • Effect of a health problem that can be observe by someone else
      • Any changes that can be physically observe
      • Signs refer to the objective data (overt) and are based on what the nurses sees.
  • OBJECTIVE DATA
    • Observable and measurable data
    • Collection of data through observation, physical examination, laboratory and diagnostic testing.
    • By gathering of information using senses of seeing hearing, smelling and touching.

    • Symptoms
      • Subjective evidence of disease
      • Only the patient can verbalize his/her feelings
      • Refer to subjective data (covert) and based on what paients say.
  • SUBJECTIVE DATA
    • The best source for finding out how someone is feeling from the person itself.
    • Personal verbalization of the patient
    • Includes information that the patient provides.

Acute vs Chronic

ACUTE

  • Minutes - 3 months up to 6 moths
  • Acute pain associated with a soft-tissue injury or brief illness. Usually goes away after the damage or illness recovers.
  • If an injury does not heal properly or if the pain signals fail, acute pain can turn into chronic pain

CHRONIC

  • CHRONIC illness lasts for months, usually more than 3
  • Might be continuous or intermittent
  • Persistent pain is pain that carries on for longer than 12 weeks despite medication or treatment.

Physical Assessment Techniques

INSPECTION

  • Examine each body system for normal and abnormal conditions using vision, smell and hearing
  • As the nurse analyzes each body system, look for color, size, position, movement, texture, symmetry, scents, and sounds.

PALPATION

  • Utilize different portions of your hands to touch the patient with varying degrees of pressure
  • Keep your fingernails short and your hands warm
  • Wear gloves- when palpating mucosal membranes or bodily fluids
  • LIGHT PALPATION
    • To feel for surface abnormalities
    • Depress the skin ½ to ¾ (about 1-2 cm) with your finger pads, lightest touch possible.
    • Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, and masses.
  • DEEP PALPATION
    • To feel internal organs and masses for size shape, tendernes, symmetry and mobility
    • Depress the skin 1 ½ to 2 inches (about 4 to 5 cm) with firm, deep pressure
    • Use one hand on top of the other to exert firmer pressure, if needed.

PERCUSSION

  • Tap your fingers or hands against sections of the patient's body fast and sharply
  • To discover organ borders, idenify organ shape and position, and if an organ is solid, fluid-filled or gas-filled
  • DIRECT PERCUSSION
    • Reveal tenderness
    • One or two fingers
    • Tap directly
    • Ask the patient to tell you which are are painful, and watch his face for signs of discomfort.
  • INDIRECT PERCUSSION
    • To elicit sounds that gives clues what makeup is in the underlaying issue.
    • Press the distal part of the middle finger of your non-dominant hand firmly on the body part.
    • Keep the rest of your hands off the body surface.
    • Flex the wrist with your non-dominant hand
    • Listen to the sound produced.

AUSCULTATION

  • Listening for lung, heart, and bowel sounds using stethoscope
  • Area is expose

Assessment process

  • Collecting Data
    • Primary source
      • Patient - alert, oriented patient is most reliable source
    • Secondary source
      • Family members, significant others, medical records and diagnostic procedure.
    • Subjective data
      • Symptoms (covert) verbal ststement by the patient
      • Ex. nausea, pain, fatigue, itching
    • Objective data
      • Signs (Overt)
      • Can be seen, felt, heard, smell- information by observation or examination.
        • Ex. discoloration skin, warm to touch, swollen part of the body.

Factors

  • Genuineness: open, sincere
  • Respect: no judgment
  • Empathy: acknowledge

Organizing data

  • Written or computerized format to organize assessment data
  • Cluster data into groups of info Format may modify acc. To Px physical status

Validating data

  • Double checking or verifying to check if accurate and factual
  • Ensures that assessment information is complete Objective and subjective data agree

Documenting Data

  • Accurate documentation is essential
  • Record in factual (no interpretation) -
  • Appropriate documentation = excellent care by accurate reflecting nursing evaluation

OVERVIEW OF NURSING PROCESS

  • Systematic, organized method of planning, and providing quality and individualized nursing care.
  • Synonymous with problem-solving approach

GOSH Approach

  • G- GOAL ORIENTED
  • O- ORGANIZED
  • S- SYSTEMATIC
  • H- HUMANISTIC CARE

Effective Nurse

  • Being able to assess and check that the patient is actually suffering from a fever.

Efficient Nurse

  • Being able to help the patient improve from one status to another through nursing interventions.

Purposes

  • To identify a client’s health status
    • The actual/present and potential/possible problems or needs.
  • Establish a Plan of care to meet identified needs.
  • Provide nursing interventions to meet those needs.
  • Provide an individualized, holistic, effective and efficient nursing care

Characteristic of the Nursing Process

  • Dynamic and cyclic
  • Patient-centered
  • Goal directed
  • Flexible
  • Problem-oriented
  • Cognitive
  • Action-oriented
  • Interpersonal
  • Holistic
  • Systematic

The Nursing Process

  • ASSESSMENT
    • Collecting subjective and objective data
    • Most critical phase
      • Is still ongoing and continuous throughout all phases of the nursing process
      • More than gathering information
      • It is analyzing and synthesizing that data, making judgements abut the effectiveness of nursing interventions and evaluations client care.
      • Systematic collection of data
      • Most important step
      • Sets the tone and the rest of the process from it.
  • Diagnosis
    • Analysis of data to identify the problem
    • Involves identifying and prioritizing actual or potential health problems or responses
    • Actual nursing diagnosis, occurring health problems for the patient
    • Potential nursing diagnoses, high risk health problem
    • Possible is that it needs further data to support it.

Types of nursing diagnosis

  • Problem-focused
    • A clinical judgement concerning an undesirable human response to a health condition
    • Ex.
      • Acute pain related to trauma of surgical incision as evidenced by facial grimace and guarding behavior.
  • Risk
    • A clinical judgment concerning the susceptibility of an individual for developing an undesirable human response to health conditions/ life processes.
    • Ex.
      • Risk for infection related to surgical incision
  • Health promotion
    • A clinical judgment concerning motivation and desire to increase well-being and to actualize health potential.
  • Syndrome
    • A clinical judgment concerning a specific cluster of nursing diagnoses that occur together and is therefore best addressed through similar interventions
  • PLANNING
    • Determining outcome criteria and developing a plan
    • Involves setting goals and outcome
      • Goals
        • Broad statement that describes a desired change in a patient’s condition, perceptions or behavior.
      • Types of goals
        • Long term goals
          • Objective behaviors
          • Response or behavior expected a patient to achieved over Longer period
        • Short term goals
          • Objective behavior
          • Achieve in short time

  • INTERVENTION
    • Always write rationale (explain why nursing interventions were made)
    • APPROACH
      • Direct care
        • Direct interventions
      • Example: medication administration, vital signs, checking etc.
    • Indirect care
      • Performed a way form a patient but behalf of the patient or group of patient
      • Example:
        • Safety and infection control, delegating nursing care
    • Tyoes
      • Independent
        • initiate s without supervision
      • Dependent
        • Order from health care provider.
      • Collaborative
        • Interdependent interventions
  • EVALUATION
    • Outcome criteria have been and revising the plan as apology

Guidelines for Documentation

  • Clear, accurate and accessible documentation is essential element of safe, quality, evidence-based nursing practice
  • critical for nurses

Uses of nursing documentation

  • Communication with the Health care Team
    • Nurses aim to share information about patients and organizational functions that is:
      • Accurate
      • Timely
      • Contemporaneous
      • Concise
      • Thorough
      • Organized
      • Confidential

Electronic Health Record (EHR)

  • Provides an integrated, real-time method of informing the health care team about the px status
  • Timely documentation of information should be made and maintained in a patient’s EHR
  • To ensure informed decisions and high quality care in the continuity of patient care.

Types of Information

  • Assessment
  • Clinical problems
  • Communication with other health care professionals regarding the patient
  • Communication with and education of the patient, family and the patient’s designated support person and other third parties.
  • Medication records (MAR)
  • Order acknowledgement, implementation and management
  • Patient clinical parameters
  • Patient responses and outcomes, including changes in the patient’s status
  • Plans of care that reflect the social and cultural framework of the patient.

Communication with Other Professionals

  • Credentialing
    • To monitor performance of health care practitioners and the health care facility’s compliance with standards governing the profession and provision of health care
  • Legal
    • Documentation that is incomplete, inaccurate, untimely, illegible or inaccessible, or that is false and misleading
      • Interfere with legal fact finding
      • Jeopardizing the legal rights, claims and defenses of both patients and health care providers
      • Putting health care organizations and providers at risks of liability
  • Regulation and legislation
    • Audits of reports and clinical documentation provide the following:
      • Method to evaluate and improve the quality of patient care
      • Maintain current standards of care
      • Provide evaluative evidence when standards require modification in order to achieve the goals, legislative mandates or address quality initiatives.
  • Reimbursement
    • Documentation is utilized to
      • Determine the severity of illness
      • The intensity of services
      • The quality of care provided
  • Research
    • Data from documentation with the patients characteristics and care outcomes
    • Evaluation and analysis are essential for attaining the goals of evidence-based practice in nursing and quality health care
  • Quality process and Performance Improvement
    • Documentation is the primary source of evidence used to continously measure performance outcomes against predetermined standards
    • Used to analyze variance from established guideline, measure, improve processes, and performance related to patient care

Nursing Documentation Principle

  • Principle 1: Documentation characteristics
    • Accessible
    • accurate , relevant and consistent
    • Auditable
    • Clear, concise, and complete
    • Thoughtful
    • Timely, contemporaneous and sequential
    • Reflective of the nursing process
    • Retrievable on a permanent basis in a nursing-specific manner
  • Principle 2: Education and Training
    • Functional and skillful use of the global documentation system
    • Competence in the use of the computer and its supporting hardware
    • Proficiency in the use of the software system
  • Principle 3: Policies and Procedures
    • The nurse must be familiar with all organizational policies and procedures
    • Policies and procedures on maintaining efficiency in the use of the “downtime” system for documentation when the available electronic system does not function.
  • Principle 4: Protection Systems
    • Security of Data
    • Protection of patient identification
    • Confidentiality of patient information
    • Confidentiality of clinical professional information
  • Principle 5: Documentation Entries
    • Accurate, valid, and complete
    • Authenticated: the information is truthful, the author is identified, and nothing has been added or inserted
    • Dated and time-stamped by the persons who created the entry
    • Legible/readable
    • Made using standardized terminology, including acronyms and symbols.
  • Principle 6: Standardized terminologies
    • Terminologies should include the terms that are used to describe the planning, delivery and evaluation of the nursing care of the patient or client in diverse settings.

Guidelines:

  • Use of the following modalities according to physician preference, if known. Wait no longer than 5 minus between attempts
    • Messenger application (if known)
    • Physicians call service
    • During weekdays, the physician's office directly
    • On weekends and after hours during the week, the physician’s mobile phone
    • Mobile phone
  • Prior to calling the physician, follow these steps:
    • Have I seen and assessed the patient myself before calling?
    • Has the situation been discussed with a resource nurse or preceptor?
    • Review the chart for the appropriate physician to call.
    • Know the admitting diagnosis and date of admission.
    • Have I read the most recent MD progress notes and notes from the nurse who worked the shift ahead of me.
    • Have the available the following when speaking with the physician:
      • Patient’s chart
      • List of current medications, allergies, IV fluids, and labs
      • Most recent vital signs
      • Reporting lab results: provide the date and time
      • Test was done and results of previous tests for comparison
      • Code status

SBAR

  • Situation
    • What is the situation you are calling about
      • Identity self . unit, patient’s full name, room number
      • Briefly state the problem, what is it, when it happened or started, and how severe.
  • Background
    • Pertinent Background information related to the situation could include the following:
      • The admitting diagnosis and date of admission
      • List of current medications, allergies, IV fluids and labs.
      • Most recent vital signs
      • Lab results: provide the date and time test was done and results of previous tests for comparisons
      • Other clinical information
      • Code status
  • Assessment
    • What’s the nurse’s assessment of the situation
  • Recommendation
    • What is the nurse’s recommendation or what does he/she want?
    • Examples;
      • Notification that patient has been admitted
      • Patient needs to be see now
      • Order change

FDAR (focus, data, action, response)

  • Guidelines:
    • Focus charting must be evident at least once every shift
    • Focus charting must be patient-oriented not nursing task-oriented
    • Indicate the date and time of entry in the first column.
    • Separate the topics words for the body of notes:
      • Focus note written on the second column
      • Data,action and response on the third column
    • Sign name for every time entry
      • Ex. Juan Dela Cruz SN
    • Document patient’s status on admission
    • Blue and black ink for AM and PM shift.
    • Red ink for NIGHT shift

Do’s :

  • Time and date all entries
  • Use flow sheet/checklists. Keep information on flowsheet current
  • Chart as you make observations
  • Sign and initial every entry
  • Described patient’s behavior and use direct patient quotes when appropriate
  • Do record exactly what happens to patient and care given
  • Factual and complete
  • Draw single line thru an error. Mark this entry as “error and sign your name”
  • Used only approved observation
  • Document patient's current status and response to medical care and treatments
  • Write legibly
  • Ink
  • Use accepted chart forms

Don’t s :

  • Begin charting until you check the name and identifying number on the patient’s chart
  • Chart procedures or care in advance
  • Don't clutter notes with Repetitive or frequently changing data already charted on the flowsheet
  • Make or sign an entry for someone else
  • Change and entry because someone tells you
  • Don't label a patient or show bias
  • Don't try to cover up mistakes or incidents by inaccuracy or omission
  • Dont whiteout or erase error
  • Dont squueze in a missed entry or “leave space for someone else who forgot to chart
  • Dont write in the margins
  • Dont use meaningless words andphrases, such as good day or no complains

Focus

  • It is the subject/purpose for the note
  • Nursing diagnosis
  • Event (admission, transfem discharge, teaching Etc).
  • Patient event or concern (code blue, vomiting, coughing etc.

Data

  • Contains a narrative of the subjective
    • WHAT DOES THE PATIENT SAID, NON-MEASURABLE
  • Objective data
    • Assessment findings, vitalssigns ang other measurable values
    • Supporting evidence for your focus
    • You wnat to writer what you did this is what the patient is saying what i m seeing

Action - What you did with patient findings - Use of verbs

Response - px response to interventio

General survey

  • Study of a Whole person
  • Covering the general health state and any obvious physical characteristics
  • Objective parameters

Getting ready

  • Wash your hands and observe standard precaution as necessary
  • Gather
  • Knock
  • Identify
  • Explain
  • Provide privacy
  • See to safety

Getting ready

  • Confirm comfort
  • Leave the call
  • See to safety
  • Open curtain
  • wash your hands
  • Report and record

Four areas

  • Physical appearance
  • Body structure
  • Mobility
  • Behavior

Physical appearance

Normal

  • Age; Appear his/her stated age
  • Sex: sexual development appropriate for their age
  • Level of consciousness: alert, oriented to person, place, time and situation.
    • Responds appropriately
  • Skin color: color tone is even, pigmentation variations, skin intact- no obvious lesions
    • Tattoos and piercing and stage healing
  • Facial features: facial features are symmetric with movement
  • Ovverall appearance:
    • No signs of acute distress are present

Abnormal

  • Age; Appear older than stated age
  • Sex; delayed puberty
  • Level of consciousness:
    • Aunt= active
    • Clara- confusion
    • Loves- lethargy
    • Oranges = Obtunded
    • snacks= Stupor
    • Cookies = Coma
  • Skin color:
    • Pallor
    • Cyanosis
    • Jaundice
    • Erythema
    • Any lesions
  • Facila features:
    • immobile , mask like, asymmetric, dropping
  • Overall apperance:
    • Cardiac respiratory signs:
      • Diaphoresis, clutching chest, shortness of breath, and wheezing.
      • pain , indicated by facial grimace, and holding body part.