Fundamentals

Types of Nursing Assessment

Initial Assessment

Also known as admission assessment.
Provides baseline data for the patient including a head-to-toe examination.

Focused Assessment

Addresses a specific problem.
Example questions include:
- "What are your signs and symptoms?"
- "What were you doing when they started?"

Emergency Assessment

A rapid assessment aimed at identifying potential fatal situations.

Patient Centered Assessment

Assesses patient using social determinants of health.
Connects potential health issues with life issues (e.g., Weight loss due to the loss of a family member).

Time Lapsed Assessment

Used to compare the patient’s current status to their previous baseline status.
Helps determine if the patient is improving or deteriorating.

Difference Between Subjective and Objective Data

Subjective Data

Refers to what the patient states and should not be solely relied upon.
Example: A patient's claim, "No, I did not have any alcohol this morning".

Objective Data

Obtained through nursing assessment without judgments or opinions, e.g.:
- Documenting patient behavior accurately such as "Patient is pacing back and forth yelling" instead of simply stating "Patient is angry".

Sources of Patient Data

Patient: The primary and best source of information.
Family/Significant Others: Important for children or patients with limited communication abilities.
Patient Record: Previous records from healthcare team members.
Medical History: Provides past care information.
Health Care Literature: Used to research unknown health problems.

Purposes of Nursing Observation, Interview, and Physical Assessment

Observation: Use of all five senses to assess consciousness and gather data based on sight, smell, touch, and hearing.
Interview: Communicates with the patient to garner additional information by employing open-ended questions.
Physical Assessment: Aims to gather objective data to assist in developing a care plan.

Interview Techniques for Obtaining Nursing History

Phases of the Interview

Preparatory Phase: Nurse prepares by reviewing the patient’s current and past records.
Intro Phase: Nurse introduces themselves and explains the purpose of their presence.
Working Phase: Nurse gathers patient's subjective data; accuracy is crucial.
Termination Phase: Concludes the interview; ensure patient feels acknowledged and inquire, "Is there anything else you'd like us to know to help us with your care?".

Common Problems in Data Collection

Failure to establish rapport with the patient.
Confusing objective and subjective information.
Not updating data.

Validating Data

Data should be kept free of bias, errors, and misinterpretation.
Data verification needed when discrepancies arise between nurse and patient's reports, or when data lacks objectivity.

Ethical Considerations

Always adhere to HIPAA (Health Insurance Portability and Accountability Act) concerning patient confidentiality.
Avoid discussing patient data on social media.
Report any significant differences in patient health to a physician immediately.

Principles of Diagnostic Reasoning

Data Verification

Recognize personal biases and maintain an open mind.
Trust clinical experience but seek guidance through dialogue with respected colleagues.

Nursing and Medical Diagnostics

Diagnostic Statements

Medical Diagnosis: Identifying the disease.
Nursing Diagnosis: Identifying unhealthy responses to health and illness.
Collaborative Problems: Involves medical interventions but also requires nursing intervention to minimize complications.

Essential Elements in Writing Nursing Diagnosis

Recognize significant data patterns or clusters.
Identify strengths, problems, and potential complications.
Clearly express the patient problem related to its etiology. An example would be assessing, "Lungs are in pain due to difficulty obtaining oxygen."

Nursing Diagnostic Statements

Link nursing diagnosis with etiology using phrasing such as “AEB” (as evidenced by).