fundamentals ch.5

Chapter 5 Assessment, Data Analysis/Problem Identification, and Planning

Learning Objectives

Theory (1 of 3)

• Identify the purpose of assessment (data collection).

• Discuss the three basic methods used to gather a patient database.

• Differentiate objective data from subjective data.

• Use sources of data for the formulation of a patient database.

Theory (2 of 3)

• Correlate patient health and wellness issues with problem statements from the Priority Problem List.

• Select appropriate outcome criteria for selected problem statements.

• Plan goals for each patient and write outcome criteria for the chosen problem statements.

Clinical Practice (3 of 3)

• Collect data for a patient and document it.

• Analyze the data collected to determine patient needs.

• Identify appropriate problem statements from the Priority Problem List for each assigned patient.

• Prioritize the problem statements.

• Write specific goal/outcome statements.

• Plan appropriate nursing interventions to assist the patient in attaining the goals/expected outcomes.

Lesson 5.1 Focus on Assessment (Data Collection)

Overview of Assessment

• The assessment phase involves the nurse collecting health data concerning the patient.

• Collected data are organized into a database and properly documented.

• Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) may be involved in collecting data as part of the assessment process.

Approaches to Assessment

• Functional health patterns assessment as formulated by Mary Gordon.

• Focused assessment: focuses on a specific issue the patient is experiencing.

• Basic needs assessment: involves evaluating needs based on Maslow’s hierarchy of basic needs.

The Interview

• The interview is primarily for gathering data rather than a social interaction.

• Effective communication is crucial, and it may be expressed through:

  • Verbal communication: spoken dialogue.

  • Nonverbal communication: body posture, facial expressions, movement, and gestures.

Stages of the Interview

1. Opening Stage: Establish rapport with the patient.

2. Body of the interview: Present necessary questions to the patient.

3. Closing Stage: Summarize the information gathered.

Medical Records Review

• Medical records serve as a tool for data collection and preparation for patient care.

• The review should include various components:

  • Face sheet and physician’s orders

  • Nurses’ notes (at least past 24 hours)

  • Physicians’ progress notes and history & physical examination

  • Medication administration record

  • Surgery operative report and pathology report

  • Diagnostic tests

  • Nursing admission history and assessment

  • Fall risk assessment and skin assessment

  • Nursing care plan or problem list.

Physical Assessment Techniques

• Utilize techniques including inspection, auscultation, palpation, and percussion, performed in a systematic head-to-toe examination manner.

• Continuous nursing data assessment focuses on body systems exhibiting problems or potential issues.

Head-to-Toe Data Collection

1. Initial Observation:

   • Breathing patterns.

   • Patient's feelings and general appearance.

   • Skin color and affect.

2. Head Assessment:

   • Level of consciousness (e.g., 'awake, alert, and oriented').

   • Communication ability (e.g., language spoken and any deficits).

   • Mentation status (e.g., comprehension and thought formation).

   • Eye appearance (e.g., pupil size and light reaction).

3. Vital Signs Assessment:

   • Temperature.

   • Pulse rate: rhythm, strength, apical, and radial assessment.

   • Respirations: rate, pattern, depth, and oxygen saturation.

   • Blood pressure: must be within normal limits and compared to previous readings.

4. Heart and Lung Assessment:

   • Assess heart sounds, specifically normal S1-S2.

   • Lung sounds including rales, wheezes, or diminished breath sounds.

   • Abdomen: evaluate shape, hardness, bowel sounds, recent voiding, appetite, and nausea.

5. Extremities Assessment:

   • Movement abilities and range, skin turgor, color and temperature, peripheral pulses, and presence of edema.

6. Assessment of Tubes and Equipment:

   • Evaluate various tubes such as oxygen cannulae, NG tubes, PEG tubes, urinary catheters, and observe for type and amount of drainage, dressings, and traction devices.

   • Assess pain status.

Assessment in Long-Term Care

• Comprehensive initial assessment conducted upon patient entry into long-term care facilities.

• Periodic reassessment at established intervals or as patient condition evolves, including:

  • Physical assessment

  • Health history

  • Medication history

  • Functional assessment.

Assessment in Home Health Care

• Initial assessments in home settings generally performed by Registered Nurses (RNs).

• LPNs/LVNs conducting private duty care in homes must document data accurately.

• Any noted changes during assessments are required to be reported to RN supervisors.

Questions

1. As part of data collection, 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:

   • assessment.

   • symptom.

   • sign.

   • observation.

2. All of the following components can be found on the chart except the:

   • face sheet.

   • physician’s order.

   • patient’s history and physical.

   • patient’s nurse assignment.

3. Linda knows as part of her nursing assignment that she is to review and update the nursing care plan on her patients:

   • hourly.

   • every shift.

   • every 24 hours.

   • weekly.

Lesson 5.2 Diagnosis

Analysis

• The database is analyzed to identify cues that deviate from normal readings.

• Data is sorted and related pieces are grouped or clustered.

• Identify and note missing data.

• Make inferences regarding the patient’s challenges based on collected data.

Nursing Diagnosis/Problem Identification

• A nursing diagnosis statement articulates the patient's current health condition or the risk of a developing issue, linking causative factors and defining characteristics (signs and symptoms).

Etiologic Factors

• Identified as the underlying causes of the problem.

• Signs: observable abnormalities verifiable through examinations (objective data).

• Symptoms: subjective feelings reported by the patient, which cannot be verified through examination.

Defining Characteristics

• Specific characteristics (signs and symptoms) that validate a relevant problem statement applied to that patient.

• These characteristics provide the necessary evidence to affirm the statement's validity.

Prioritization of Problems

• Problems are ranked based on their importance:

  • Physiologic needs necessary for basic survival (i.e., airway management and circulation) take precedence.

  • Safety issues hold secondary importance.

  • Nurses should consider each patient holistically, addressing psychosocial needs alongside physical concerns.

Problem Statements in Long-Term and Home Health Care

• Long-term care: LPN/LVN develops the care plan upon admission and the supervising RN reviews and finalizes it.

• Home health care: Problem statements should address issues identified in family coping and any teaching requirements related to patient care; care planning encompasses both the patient and their family.

Questions

4. Which one of the following sets of data is most likely to be present with the nursing diagnosis Risk for infection?

   • Fever, dysuria, change in urine concentration, urinary urgency.

   • Abdominal pain, sore mouth, hyperactive bowel sounds, leukopenia.

   • Fatigue, electrocardiographic changes, dependent edema, activity intolerance.

   • Abdominal incision, decreased hemoglobin, and indwelling catheter present.

Lesson 5.3 Planning

Expected Outcomes in Planning

• Goal: The intended achievement resulting from nursing interventions.

  • Short-term goals: Achievable within 7 to 10 days or before discharge.

  • Long-term goals: May require weeks or months to achieve and often link to rehabilitation.

• Expected outcome: A statement depicting the goal that the patient should achieve as a result of nursing intervention.

Interventions (Nursing Orders)

• Interventions aim to combat identified problems and attain expected outcomes.

• They may include medication administration and performing prescribed treatments tailored to each patient's specific requirements.

Documentation

• The documentation of plans is crucial; the plan must become part of the patient’s medical record.

• Any plans created by LPNs/LVNs require an RN's review before inclusion in the chart.

• The care plan should be evaluated and updated at least every 24 hours.

Question

5. A nurse has established expected outcomes for an assigned patient. The nurse carries out this important activity for the purpose of:

   • evaluating the occurrence of complications.

   • measuring the quality of care.

   • measuring the effectiveness of the nursing interventions.

   • stopping care when the outcomes are met.