Chapter 5: Assessment, Data Analysis/Problem Identification, and Planning
Lesson 5.1: Assessment (Data Collection) Theory
Purpose of Assessment
The primary purpose of assessment is to gather health data to identify the patient's status and needs.
During the assessment phase, the nurse collects patient health data, which are then gathered on specific topics, organized into a database, and documented.
LPN/LVNs may be requested to assist in collecting data as part of the overall assessment process.
Approaches to Assessment
Functional Health Patterns Assessment: An approach formulated by Mary Gordon.
Focused Assessment: This approach focuses specifically on a single problem or area of concern.
Basic Needs Assessment: Based on Maslow’s hierarchy of basic needs, prioritizing fundamental requirements for human life.
Methods of Data Collection
The Interview: This is a structured interaction based on gathering data rather than a social interaction. Good communication is essential and includes:
Verbal Communication: Spoken exchange of information.
Nonverbal Communication: Noting body posture, facial expressions, movements, and gestures.
Stages of the Interview:
The Opening: During this stage, rapport is established with the patient.
The Body: During this stage, necessary questions are presented to the patient.
The Closing: During this stage, the gathered information is summarized.
Medical Records (Chart) Review
The chart review is a data collection tool used to obtain information for the patient interview or to prepare for the day’s assignment. A comprehensive review should include:
Face sheet and physician’s orders.
Nurses’ notes (covering at least the past hours).
Physicians’ progress notes, history, and physical examination.
Medication administration record (MAR).
Surgery operative report and pathology report.
Diagnostic test results.
Nursing admission history and assessment.
Fall risk assessment and skin assessment.
Nursing care plan or problem list.
Physical Assessment Techniques and Systematic Review
Methods of Physical Assessment
Inspection: Visual observation of the patient.
Auscultation: Listening to sounds within the body.
Palpation: Using touch to feel textures, sizes, and consistencies.
Percussion: Tapping on the body surface to produce sounds.
Head-to-Toe Assessment Overview
Assessments are carried out in a systematic manner. Ongoing nursing data collection focuses on body systems where there is an existing or potential problem.
Initial Observation Items:
Breathing.
How the patient is feeling.
General appearance.
Skin color.
Affect.
Assessment of the Head:
Level of Consciousness: Determined if the patient is awake, alert, and oriented.
Ability to Communicate: Assessing the language spoken and any communication deficits.
Mentation Status: Assessing the ability to comprehend and form thoughts.
Eyes: Appearance of the pupils, including size and reaction to light.
Vital Signs:
Temperature.
Pulse Rate: Assessing rhythm, strength, and locations such as apical or radial.
Respirations: Rate, pattern, depth, and oxygen saturation ( Sat).
Blood Pressure: Determining if it is within normal limits and comparing it with previous readings.
Heart and Lungs:
Heart: Checking for normal and sounds.
Lungs: Assessing lung sounds and checking for rales, wheezes, or diminished breath sounds.
Abdomen:
Shape and hardness.
Bowel sounds.
History of the last bowel movement.
Voiding status.
Appetite and presence of nausea.
Extremities:
Ability to move all extremities well and within a normal range.
Skin turgor, color, and temperature.
Presence and quality of peripheral pulses.
Presence of edema.
Tubes and Equipment:
Oxygen cannula and chest tubes.
NG (Nasogastric) tubes, PEG (Percutaneous Endoscopic Gastrostomy) tubes, and jejunostomy tubes.
Urinary catheter (including type and amount of drainage).
Dressings and drainage.
Pulse oximeter.
Traction devices.
Pain status.
Assessment in Specialized Care Settings
Long-Term Care Assessment
An extensive initial assessment is performed upon entry.
Reassessment occurs at fixed intervals and whenever the patient's condition changes.
Assessments involve physical evaluation, health history, medication history, and functional assessment.
Home Health Care Assessment
The initial assessment in the home is usually the responsibility of the Registered Nurse (RN).
LPN/LVNs working in private duty must perform daily assessments and maintain documentation.
All changes found during assessment must be reported to the RN supervisor.
Lesson 5.2: Diagnosis and Data Analysis
Process of Analysis
The database is analyzed for "cues" that deviate from the norm.
Data pieces are sorted and related data are grouped or "clustered."
Missing data are identified, and inferences are made regarding the patient's problems.
Nursing Diagnosis / Problem Identification
A nursing diagnosis statement indicates the patient's actual health status or the risk of a problem developing.
It includes causative or related factors and specific defining characteristics (signs and symptoms).
Etiologic Factors (Causes)
Signs: Abnormalities that can be verified by repeat examination (Objective Data).
Symptoms: Data the patient states is occurring that cannot be verified by examination (Subjective Data).
Defining Characteristics
These are the specific signs and symptoms that must be present for a particular problem statement to be appropriate for a patient.
They supply the evidence validating the problem statement.
Prioritization of Problems
Problems are ranked by importance.
Physiologic Needs: Basic survival needs (e.g., airway and circulation) take precedence.
Safety: Safety problems are prioritized after physiologic needs.
Holistic Approach: Nurses must look at each patient holistically, meeting psychosocial needs while addressing physical problems.
Problem Statements in Specific Settings:
Long-Term Care: LPN/LVNs begin the care planning process at admission. The RN reviews, modifies, and finalizes the plan.
Home Health Care: Statements must include factors related to the family’s ability to cope and identifying teaching needs. The plan encompasses the patient and the whole family.
Lesson 5.3: Planning and Interventions
Expected Outcomes
Goal: What is to be achieved by nursing intervention.
Short-term Goals: Achievable within to days or before discharge.
Long-term Goals: Take many weeks or months to achieve; often relate to rehabilitation.
Expected Outcome: A statement of the goal the patient is to achieve as a result of nursing intervention.
Nursing Interventions (Nursing Orders)
Designed to alleviate problems and achieve expected outcomes.
They include giving medications and performing ordered treatments.
They must be individualized to the patient's specific needs.
Documentation and Review
Planning is not complete until it is documented in the medical record.
Plans constructed by LPN/LVNs must be reviewed by the RN before being placed in the chart.
The plan of care must be reviewed and updated once every hours.
Questions & Discussion
Question 1: As part of an assessment, the nurse asks for information from the patient. This information is a subjective indication of illness perceived by the patient and is called a/an:
1) assessment.
2) symptom.
3) sign.
4) observation.
Question 2: All of the following components can be found on the chart except the:
1) face sheet.
2) physician’s order.
3) patient’s history and physical.
4) patient’s nurse assignment.
Question 3: Linda knows as part of her nursing assignment that she is to review and update the nursing care plan on her patients:
1) hourly.
2) every shift.
3) every hours.
4) weekly.
Question 4: Which one of the following sets of assessment data is most likely to be present with the nursing diagnosis "Risk for infection"?
1) Fever, dysuria, change in urine concentration, and urinary urgency.
2) Abdominal pain, sore mouth, hyperactive bowel sounds, and leukopenia.
3) Fatigue, electrocardiographic changes, dependent edema, and activity intolerance.
4) Abdominal incision, decreased hemoglobin, and indwelling catheter present.
Question 5: A nurse has established expected outcomes for an assigned patient. The nurse carries out this important activity for the purpose of:
1) evaluating the occurrence of complications.
2) measuring quality of care.
3) measuring the effectiveness of nursing interventions.
4) stopping care when outcomes are met.
Practice Test: Assessment (Data Collection) Theory
Multiple Choice Questions
What is the primary purpose of assessment in nursing?
A) To gather health data to identify the patient's status and needs.
B) To provide therapeutic communication.
C) To administer medications.
D) To develop a nursing care plan.
Which of the following assessment approaches is based on Maslow’s hierarchy of basic needs?
A) Functional Health Patterns Assessment
B) Focused Assessment
C) Basic Needs Assessment
D) Comprehensive Assessment
During which stage of the interview is rapport established with the patient?
A) The Body
B) The Opening
C) The Closing
D) The Review
What is NOT included in the comprehensive chart review?
A) Face sheet
B) Physician’s orders
C) Nursing assignments
D) Diagnostic test results
Which physical assessment technique involves visual observation of the patient?
A) Auscultation
B) Palpation
C) Inspection
D) Percussion
Short Answer Questions
Describe the role of LPN/LVNs in the assessment process.
What are the primary vital signs a nurse should assess during a physical examination? List them.
Define the term "nursing diagnosis" and explain its importance in patient care planning.
What factors are considered in the prioritization of nursing problems?
Explain why documentation and review are crucial steps in the planning phase of nursing care.