CH 5 FON

Assessment: Data Collection Theory and Methods

• Purpose: The nurse collects patient health data to organize into a documented database. LPN/LVNs assist in this collection.
• Assessment Approaches:
  • Mary Gordon: Functional health patterns.
  • Focused Assessment: Targets a specific problem.
  • Maslow’s Hierarchy: Based on basic human needs.
• Gathering Data:
  • Interview Stages: Opening (establishing rapport), Body (questioning), and Closing (summarizing).
  • Medical Record (Chart) Review: Analysis of face sheet, physician orders, medication administration records, diagnostic tests, and nursing notes (past $24\,\text{hours}$).
  • Physical Assessment: Systematic head-to-toe examination using inspection, ausculation, palpation, and percussion.

Clinical Head-to-Toe Assessment Components

• Initial Observation: Breathing, general appearance, skin color, and affect.
• Neurological/Head: Level of consciousness (awake, alert, oriented), ability to communicate, mentation, and pupil size/light reaction.
• Vital Signs: Temperature, pulse (apical and radial), respirations (rate, depth, oxygen saturation), and blood pressure compared to previous readings.
• Body Systems:
  • Heart and Lungs: Normal $S_1 - S_2$ sounds; checking for rales, wheezes, or diminished breath sounds.
  • Abdomen: Bowel sounds, shape, and voiding patterns.
  • Extremities: Range of motion, peripheral pulses, edema, and skin turgor.
• Equipment: Monitoring oxygen cannulas, chest tubes, feeding tubes (NG, PEG, jejunostomy), urinary catheters, and traction devices.

Diagnosis and Problem Identification

• Analysis: Sorting data cues, clustering related data, and making inferences about deviations from the norm.
• Nursing Diagnosis Statement: Indicates actual status or risk, causative (etiologic) factors, and defining characteristics (signs and symptoms).
• Data Types:
  • Signs (Objective): Abnormalities verified by examination.
  • Symptoms (Subjective): Patient-reported data that cannot be verified by examination.
• Prioritization: Physiologic survival needs (airway and circulation) take precedence, followed by safety and psychosocial needs.

Planning and Expected Outcomes

• Goals:
  • Short-term: Achievable within $7$ to $10\,\text{days}$ or before discharge.
  • Long-term: Take weeks or months; often related to rehabilitation.
• Outcome Criteria: Specific statements of what the patient should achieve through nursing interventions.
• Interventions (Nursing Orders): Individualized actions designed to alleviate problems, including medications and ordered treatments.
• Documentation: The care plan must be reviewed by an RN and updated every $24\,\text{hours}$.

Care in Specific Settings

• Long-Term Care: Includes extensive initial assessments and reassessment at fixed intervals. LPN/LVNs begin the process, but the RN finalizes the plan.
• Home Health Care: Initial assessment is usually performed by the RN. LPN/LVNs in private duty perform daily assessments and must report changes to the RN supervisor.

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:
  • Answer: 2) symptom.
• Question 2: All of the following components can be found on the chart except the:
  • Answer: 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:
  • Answer: 3) every $24\,\text{hours}$.
• Question 4: Which one of the following sets of assessment data is most likely to be present with the nursing diagnosis Risk for infection?
  • Answer: 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:
  • Answer: 3) measuring the effectiveness of nursing interventions.