In class test NP1

WEEK 1

By the end of this week you should be able to:

• Outline chain of infection and identify factors associated with healthcare-associated infections (HAIs)

• Explore the signficance and effects of healthcare-associated infections

• Demonstrate National Hand Hygiene Initiative five moments for hand hygiene

• Demonstrate the ability to assess and select appropriate personal protective equipment (PPE)

**Chain of Infection**

1. **Aetiological Agent (Micro-organism)**:

* The pathogen responsible for causing infection.

* Examples: bacteria, viruses, fungi, protozoa, parasites.

2. **Reservoir (Source)**:

* The habitat in which the agent normally lives, grows, and multiplies.

* Examples: humans, animals, insects, environment (soil, water, surfaces).

3. **Portal of Exit from Reservoir**:

* The path by which the agent leaves the reservoir.

* Examples: respiratory tract (coughing, sneezing), gastrointestinal tract (feces, vomit), blood, skin.

4. **Method of Transmission**:

* How the agent is transferred from the reservoir to a susceptible host.

* Direct transmission: direct contact, droplet spread, vertical transmission.

* Indirect transmission: airborne, vehicle-borne (contaminated objects), vector-borne (insects).

5. **Portal of Entry to Susceptible Host**:

* The path by which the agent enters the host.

* Examples: respiratory tract, gastrointestinal tract, skin, mucous membranes.

6. **Susceptible Host**:

* An individual who is vulnerable to the infection.

* Factors increasing susceptibility: age, weakened immune system, chronic diseases, invasive medical procedures.

**Healthcare-Associated Infections (HAIs)**

* Infections acquired in a healthcare setting.

* **Significance**:

* Common: 165,000 HAIs each year.

* Preventable: Effective infection prevention and control are crucial.

* Costly: Increase healthcare costs and length of hospital stays.

* **Effects**:

* Increased morbidity and mortality.

* Prolonged hospital stays.

* Increased healthcare costs.

* Emotional and financial burden on patients and families.

**National Hand Hygiene Initiative: Five Moments for Hand Hygiene**

1. Before touching a patient.

2. Before clean/aseptic procedures.

3. After body fluid exposure risk.

4. After touching a patient.

5. After touching patient surroundings.

**Personal Protective Equipment (PPE)**

* **Gloves**:

* Protect hands from body substances.

* Reduce the spread of microorganisms.

* Single-use only.

* **Gowns**:

* Protect skin and clothing from contamination.

* Use when there is a risk of contamination with blood, body fluids, secretions, or excretions.

* **Face Masks**:

* Protect the respiratory tract from droplets and aerosols.

* Use single-use surgical masks or particulate respirators (P2/N95).

* **Eyewear**:

* Protect eyes from splashes and sprays of body fluids.

* Use goggles, glasses, or face shields.

**Additional Key Points**

* **Standard Precautions**: Hand hygiene, use of PPE, respiratory hygiene, safe handling of sharps, aseptic technique.

* Aseptic non-touch technique (ANTT)

* Respiratory hygiene & etiquette (What, when, how?)

* **Transmission-Based Precautions**: Additional precautions for patients with known or suspected infections (contact, droplet, airborne).

* Measures adopted depends on the route of transmission:

* PPE dedicated to mode of transmission

* Patient-dedicated equipment

* Single room or cohort of patients

* Air handling requirements

* Enhanced cleaning & disinfection of patient environment

* Restricted transfer of patients between facilities

* **Psychosocial Needs**: Addressing the emotional and social needs of patients in isolation.

* Feelings!

* To prevent these:

* Adopt a patient-centred approach; explain the infection and associated precautions

* Do not use stricter precautions than needed

* Demonstrate warm, accepting behaviour and initiate communication and diversionary, stimulation activities

* **What does this mean for you?**

* Be aware of current policies and guidelines on infection prevention and control

* Follow local health facility policies and procedures

* Be aware of current research and best practice guidelines

* Become knowledgeable and skilful in risk management

* Practice safely and competently, for example: implement infection control practices such as hand hygiene and standard & transmission precautions.

Week 2

By the end of this week you should be able to:

• Apply therapeutic communication skills and a person centred approach to client care

• Demonstrate nursing assessment and skill in assisting with personal hygiene

• Utilise best practice when making an occupied and unoccupied bed

• Demonstrate safety in assisting a person to reposition

I. Introduction to Evidence-Based Practice (EBP)

• A. Defining a Profession

  • Historically, nursing was often seen as a menial job, lacking required education and practice standards.

  • As society progressed, the vital role of nurses in health maintenance became recognized.

  • Nurses advocated for the professionalization of nursing to gain recognition.

  • A profession requires:

    • Discipline-specific regulation.

    • A specialized body of knowledge and skills.

    • Education.  

  • Accountability is a key characteristic of a profession, demonstrated by its members and the profession's overall accountability and autonomy.  

• B. Role of the Registered Nurse (RN)

  • The registered nurse provides evidence-based nursing care to individuals of all ages and cultural backgrounds.  

  • Responsibilities include:

    • Health promotion and maintenance.

    • Illness prevention.

    • Alleviation of pain and suffering.

    • Assessment, planning, implementation, and evaluation of nursing care in collaboration with individuals and multidisciplinary teams.

    • Holistic caregiving, recognizing the impact of physical, psychological, emotional, cognitive, and spiritual factors on health.  

  • RNs provide care in various settings and take a leadership role in coordinating nursing and healthcare across different contexts to optimize health. They also refer and coordinate care as needed.  

  • All activities of a Registered Nurse are evidence-based.  

  • The registered nurse contributes to quality healthcare through:

    • Lifelong learning.

    • Professional development.

    • Research.

    • Clinical supervision.

    • Development of policy and clinical guidelines.  

  • RNs develop professional practice according to the health needs of others and the changing patterns of disease and illness.  

• C. Nurses' Responsibilities

  • Nurses must understand and adhere to the standards set by the profession.  

  • Nurses are accountable to themselves, consumers, the community, other healthcare professionals, and employers.  

  • Accountability includes responsibility for the appropriateness, quality, and cost of healthcare provided, which is demonstrated through decisions and actions.  

  • A commitment to ongoing competence and continued learning is essential.  

  • Higher education is crucial for professionalism in nursing, and RN education must be delivered by an accredited higher education provider.  

II. Evidence-Based Practice (EBP) in Nursing

• A. Definition

  • Evidence-Based Practice (EBP) involves the conscientious, explicit, and judicious use of current best evidence in making decisions about patient care.  

• B. Florence Nightingale's Contribution

  • Florence Nightingale is recognized as an EBP pioneer.  

  • In January 1858, she published a report detailing her observations from the Crimean War: "Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army."  

  • Her evidence demonstrated that disease, not war injuries, was the primary cause of mortality in the British Army during the Crimean War.  

  • Nightingale’s work led to the introduction of standardized hygiene procedures in hospitals worldwide, resulting in a rapid decrease in infection rates.  

  • She also supervised the modernization of nursing by implementing simple sanitary measures and influenced hospital designs globally.  

• C. Importance of EBP

  • EBP leads to better outcomes for patients.  

  • It drives updates in procedures and policies.  

  • EBP enhances nurses' autonomy and professional credibility.  

  • It demonstrates the value of nursing and provides nurses with opportunities to deliver cost-effective care.  

• D. Triad Approach of EBP

  • In 2000, the definition of EBP was expanded to include patient values and clinical expertise.  

  • EBP is a triad approach to practice, informed by the best available research evidence, clinical expertise, and client preference.  

  • This concept is likened to a three-legged stool: the removal of any leg will cause the stool to fall.  

• E. Components of the Triad Approach

  • Best Research Evidence:

    • Evidence is generated through systematic investigation.  

  • Clinical Expertise:

    • Based on a strong knowledge base.  

    • Develops over time through clinical experience.  

    • Obtained from observation and learning from other clinicians.  

    • Nurses should continuously evaluate their practice and seek new knowledge, requiring a minimum of 20 hours of Continuing Professional Development (CPD) points per year.  

  • Patient Preference:

    • The chosen approach should align with the patient's agreement.  

    • Patient preferences should be considered when applying evidence-based practice.  

    • However, practice must still be evidence-based.  

    • Patients have the right to refuse treatment.

    • Example: When choosing between Antibiotic A (more effective, clears infection in 5 days) and Antibiotic B (less effective, clears infection in 8 days), the seemingly obvious choice is Antibiotic A.  

  • Clinicians integrate their expertise with the best available evidence in delivering care.  

  • Patient's illness conditions, rights, and preferences are considered in clinical decisions about their treatment.  

III. Sourcing and Retrieving Information

• A. Information Sources

  • Evidence can be sourced from various places.  

  • Information levels range from word-of-mouth and personal observation to published scientific research (the "gold standard").  

  • In nursing, patients, their relatives, and carers are crucial information sources.  

  • Methods for collecting and communicating information from patients and stakeholders will be covered in week 3.  

  • Regardless of the source, evidence must be corroborated and credible.  

• B. Credibility of Evidence Sources

  • Here's a breakdown of source availability, accessibility, and credibility:

    • Journals: Most common location, easy to find, high credibility.  

    • Books: Relatively rare, harder to find, good credibility but may not be current.  

    • Textbooks: Unlikely to find full reports, good credibility but may not be current.  

    • Theses: Common location, can be difficult to find, unclear credibility.  

    • Websites: Can be found, full reports often unavailable, unclear credibility (not recommended).  

    • Mass and Social Media: May be mentioned, full reports unavailable, unclear credibility (locate the original source).  

• C. Levels of Evidence

  • Higher levels of evidence indicate greater credibility.  

  • Nurses can also conduct research to test information, potentially increasing its level of evidence.  

• D. Seven Levels of Evidence

  • Here are the seven levels of evidence, ranked from most to least reliable:

    • Level I: Systematic reviews and analysis (Most reliable).  

    • Level II: Critically appraised topics (Very high reliability).  

    • Level III: Critically appraised articles (Increasing reliability).  

    • Level IV: Randomized controlled trials (Very reliable - gold standard).  

    • Level V: Cohort studies (Becoming more reliable).  

    • Level VI: Case series and case reports (Slightly more reliable).  

    • Level VII: Ideas, opinions, editorials, anecdotes (Least reliable).  

Person-Centered Care

• A. Core Elements

  • Person-centered care emphasizes:

    • Trust  

    • Empathy  

    • Dignity  

    • Autonomy  

    • Respect  

    • Choice  

    • Transparency  

• B. Case Scenario: Mrs. Peterson

  • Mrs. Peterson resides in Pinewood Aged Care facility.  

  • She is generally in good spirits but experiences mild cognitive decline due to dementia.  

  • She has difficulty remembering names, faces, and recent events but retains clear memories of her childhood and family.  

  • Mrs. Peterson enjoys sitting outside in her garden and having afternoon tea.  

  • She has mobility issues due to osteoarthritis, limiting her movement.  

• C. Communication with Older People

  • Strategies for effective communication include:

    • Use of assistance devices  

    • Communication aids  

    • Minimizing environmental distractions  

    • Allowing sufficient time for communication  

    • Speaking in short, simple sentences  

    • Using touch (when appropriate)  

    • Appropriate positioning  

    • Involving family and friends  

II. Hygiene

• A. Components of Hygiene

  • Hygiene involves care of:

    • Skin  

    • Hair  

    • Nails  

    • Teeth  

    • Oral and nasal cavities  

    • Eyes  

    • Ears  

    • Perineal-genital areas  

  • Hygiene practices include:

    • Bathing  

    • Toileting  

    • General body hygiene  

    • Grooming  

• B. Purpose of Hygiene

  • Hygiene promotes:

    • Comfort  

    • Cleanliness  

    • Infection control  

    • Positive body image  

    • Mental well-being  

• C. Factors Influencing Hygiene Practices

  • (The slides prompt for input on this, but do not provide specific answers)  

• D. Hygiene Safety

  • Safety considerations include:

    • Checking the Nursing Care Plan  

    • Obtaining permission and ensuring privacy  

    • Adhering to standard precautions  

    • Using correct equipment  

    • Applying ergonomic principles  

    • Ensuring a safe environment  

• E. Skin

  • Functions of the skin:

    • Protects underlying tissues from injury by preventing microorganism passage  

    • Regulates body temperature  

    • Secretes sebum  

    • Transmits sensations through nerve receptors  

    • Produces and absorbs vitamin D  

• F. Assessing Hygiene Needs

  • Assessment involves:

    • Nursing health history  

    • Physical assessment  

    • Identification of individuals at risk  

• G. Self-Care Deficits

  • Factors contributing to self-care deficits:

    • Decreased or lack of motivation  

    • Weakness or tiredness  

    • Pain or discomfort  

    • Perceptual cognitive impairment  

    • Neuromuscular or musculoskeletal impairment  

• H. Lifespan Considerations

  • Bathing considerations vary across the lifespan:

    • Infants  

    • Children  

    • Adolescents  

    • Older adults  

  • Skill 34.1 in Berman et al. (2023) provides guidance on bathing an adult, child, or young person.  

• I. General Guidelines for Skin Care

  • Important to prevent injury and irritation  

  • Poorly nourished and dry skin is more prone to injury  

  • Ensure skin is dried carefully  

  • Cleanliness is the best deodorant  

  • Skin sensitivity is greater in infants, young children, and older people  

• J. Bathing Types

  • Types of baths include:

    • Complete bed bath  

    • Self-help bed bath  

    • Partial bath (face, hands, and back)  

    • Bath  

    • Sponge baths  

    • Shower  

• K. Mouth Care

  • Oral hygiene involves:

    • Gums care  

    • Mechanical brushing and flossing of teeth  

    • Flushing of the mouth  

  • Skills 34.4 and 34.5 in Berman et al. (2023) cover brushing/flossing teeth and special oral care for unconscious persons.  

• L. Eye Care

  • Berman et al. (2023) provides information on eye care (pages 790-792).  

• M. Ear Care

  • Skill 34.8 in Berman et al. (2023) details removing, cleaning, and inserting a hearing aid (pages 792-794).  

• N. Nose Care

  • (The slides include "Nose Care" but provide no details)  

• O. Home Care Considerations

  • Home care involves considering:

    • The person and their environment  

    • Family  

    • Community  

III. Making Beds

• A. Bed Making Types

  • Types of bed making include:

    • Unoccupied bed  

    • Changing an occupied bed  

  • Skills 34.9 and 34.10 in Berman et al. (2023) cover changing unoccupied and occupied beds.  

IV. Client Positioning

• A. Positions

  • Positions include:

    • Fowler's (and Semi-Fowler's)  

    • Standard Lateral Decubitus (Lateral)  

    • Prone  

    • Orthopneic  

    • Supine (Recumbent)  

V. Person-Centered Care (Additional Resource)

• The Aged Care Quality and Safety Commission provides a video on person-centered care.  

WEEK 3 - THINK LIKE A NURSE

Lecture Notes: Thinking Like a Nurse & Clinical Reasoning

Week Objective:

• Explain what it means to 'think like a nurse'.

• Describe the process of clinical reasoning.

• Identify the stages of the clinical reasoning cycle.

• Examine how nurses use clinical reasoning during the provision of care.

I. Thinking Like a Nurse

• A. Connection to RN Standards

  • The Nursing and Midwifery Board of Australia (NMBA) Registered Nurse Standards for Practice highlight the importance of critical thinking and analysis in nursing practice.

  • Specifically, Standard 1 states: "Thinks critically and analyses nursing practice."  

• B. Critical Thinking Defined

  • Critical thinking is a complex process involving cognitive skills and affective habits of the mind.

  • It can be described as analyzing and assessing thinking to improve it.  

  • Critical thinking involves examining beliefs and knowledge in light of the evidence that supports them.  

  • Nurses primarily use critical thinking for problem-solving and decision-making.  

  • Critical thinking leads to clinical reasoning, which is essential for making decisions and taking action to achieve positive patient outcomes.  

  • Critical thinking includes:

    • Creativity

    • Problem-solving

    • Decision-making

  • Critical thinking is essential for safe, competent, and skillful nursing practice.  

  • It involves using scientific knowledge and the nursing process to consider a client's specific situation and make clinical judgments.  

• C. What "Thinking Like a Nurse" Entails

  • Thinking like a nurse is complex and challenging.  

  • It requires a strong foundation of knowledge and clinical reasoning skills.  

  • Adequate clinical reasoning skills are crucial for providing safe, effective, and evidence-based care.  

• D. Skills Involved in Critical Thinking

  • Reflection

  • Creativity

  • Critical analysis

  • Clinical reasoning

  • Divergent thinking

  • Clarifying

• E. Importance of Critical Thinking in Nursing

  • The healthcare environment is constantly changing.  

  • There is increased complexity in patient conditions, including co-morbidities.  

  • There is increased consumer involvement in healthcare.  

  • Increased use of technology in healthcare.  

  • Emphasis on evidence-based practice.  

  • New problems require new ways of thinking.  

  • Autonomy and responsibility in nursing necessitate a professional level of thinking.  

II. Clinical Reasoning

• A. Definition

  • Clinical reasoning is the process by which nurses (and other clinicians) collect cues, process information, understand a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process.  

• B. The Clinical Reasoning Cycle

  • The clinical reasoning cycle is a model used to enhance nurses' ability to identify and manage clinically "at-risk" patients.  

  • Stages of the Clinical Reasoning Cycle:

    1. Consider the patient situation:

       • Describe the context of the client’s presenting situation.

       • Identify possible problems and outcomes for the person.

       • Describe or list facts, context, objects, or people involved.  

    2. Collect cues and information:

       • Review current information: handover reports, patient history, patient charts, results of investigations, nursing and medical assessments previously undertaken.  

       • Gather new information: undertake patient assessment.  

       • Recall knowledge: physiology, pathophysiology, pharmacology, epidemiology, context of care, ethics, law.  

    3. Process that information:

       • Interpret: Analyze data; compare normal vs. abnormal.  

       • Discriminate: Distinguish relevant from irrelevant information, narrow down information, recognize gaps.  

       • Relate: Cluster cues together and identify relationships.  

       • Infer: Interpret the subjective and objective cues and form opinions.  

       • Match: Current situation to past situations (expert thought process).  

       • Predict: An outcome (expert thought process).  

    4. Identify problems and issues:

       • Synthesize facts and inferences to make a definitive diagnosis of the patient's problem.  

    5. Establish goals:

       • Describe what you want to happen, a desired outcome, and a timeframe.  

    6. Take action:

       • Select a course of action.  

    7. Evaluate:

       • Evaluate the effectiveness of the outcomes and actions.  

    8. Reflect on process and new learning:

       • Contemplate what you have learned from the process and what you could have done differently.  

WEEK 4 - THERAPUTIC RELATIONSHIPS

Therapeutic Communication in Nursing

• Definition: Communication is a fundamental nursing skill that ensures safe, collaborative, and effective care. It involves gathering, sharing, and validating assessment data, understanding individual patient needs and health experiences, and expressing care and comfort. It is also crucial for maintaining a therapeutic nurse-patient relationship and collaborating with the healthcare team.  

• Importance of Effective Communication in Healthcare: Effective and coordinated communication is essential in healthcare settings to ensure patient safety and quality care.

• Communication Goals Specific to Nursing:

  • Gathering information

  • Building professional therapeutic relationships

  • Assessment

  • Evaluation

  • Critical thinking

  • Diagnosis

  • Planning

  • Implementation  

• Registered Nurse Standards for Practice: The Nursing and Midwifery Board of Australia emphasizes therapeutic and professional relationships as a key standard for practice.  

• Levels of Communication:

  • Intrapersonal (self-awareness)

  • Interpersonal

  • Group/organizational

  • Mass  

• Interpersonal Communication:

  • Involves the exchange of information, feelings, and meaning through verbal and non-verbal messages between two or more people.

  • Utilizes both verbal and non-verbal methods.  

• Verbal Communication Methods:

  • The use of words in delivering a message, either written or spoken.  

• Non-Verbal Communication Methods:

  • Sending and receiving wordless messages through body language, including facial expressions, eye contact, posture, and gestures.

  • Other methods include electronic, mechanical, computer technology, hearing aids, visual symbols, and signage.  

• Verbal Communication: Effective verbal communication involves:

  • Language

  • Simplicity

  • Avoiding jargon

  • Clarity

  • Timing

  • Relevance

  • Adaptability

  • Credibility  

• Non-Verbal Communication: Includes:

  • Body language

  • Appearance

  • Posture and gait

  • Facial expression

  • Eye contact/movements

  • Gestures/body movement

  • Touch

  • Proxemics (use of space)

  • Vocalics (pitch, pace/rate, intonation/emphasis, volume)

  • Silence and pauses

  • Vocalizing without words (laughing, crying)  

• Skills in Communication:

  • Person-centered

  • Active listening or reading

  • Empathetic understanding

  • Cultural competence  

• Person-Centered Care: Focuses on:

  • Trust

  • Empathy

  • Dignity

  • Autonomy

  • Respect

  • Choice

  • Transparency  

• Nurse as a Therapeutic Agent: Skills include:

  • Attending

  • Listening

  • Questioning  

• Attending: Involves:

  • The spatial position of the nurse in relation to the patient.

  • Maintenance of eye contact.

  • Demonstrates active interest in the patient.  

• SOLER Acronym for Attending:

  • S: Sit squarely

  • O: Open posture

  • L: Lean forward

  • E: Eye contact

  • R: Relaxed posture  

• Listening:

  • Essential for establishing effective relationships in nursing practice.

  • Active listening demonstrates that nurses care about patients’ wellbeing.  

• Questioning:

  • Probing skills used in assessment, interviewing, and effective exploration.

  • Types of questions include open, closed, probing, clarifying, and leading (which should be avoided).  

• Types of Questions:

  • Open: “Tell me why you are here today.”  

  • Closed: “Do you have any allergies?”  

  • Probing: “Tell me more about what you are allergic to?”  

  • Clarifying: “You said you are allergic to penicillin, is that correct?”  

  • Leading (avoid): “You don’t have any allergies to this medicine, do you?”  

Cultural Competence and Cultural Safety

• Culture:

  • The result of shared geography, time, ideas, and human experience.

  • May or may not involve kinship.

  • Meanings and understandings are collectively held by group members.

  • Dynamic and mobile, changing according to time, individuals, and groups.  

• Cultural Competence:

  • The ability to establish effective interpersonal and working relationships that go beyond cultural differences.

  • Involves recognizing the importance of social and cultural influences on patients, considering how these factors interact, and devising interventions that address these issues.  

• Cultural Safety:

  • A complex act grounded in critical reflection and action.

  • Healthcare professionals use it to provide culturally safe, congruent, and effective care in partnership with individuals, families, and communities, considering the social and political dimensions of care.  

• Cultural Considerations:

  • Communication and culture are closely interconnected.

  • Involve verbal communication (language, dialect, slang, medical jargon), cultural values, and personal information.

  • Nurses should ensure interpreters are used (not family members or children) and conduct cultural assessments.  

• Providing Cultural Nursing Care: Requires that nurses ask themselves:

  • What do I know about Indigenous Australian culture?

  • Are there gaps in my knowledge?

  • Where has my knowledge come from?

  • Have I explored my biases?

  • Do I know the history of Indigenous Australians and their interactions with European colonizers?

  • How would I feel about the history, treatment, and others’ perceptions from the perspective of an Indigenous Australian?  

• Providing Culturally Safe Care: Involves:

  • Reflecting on historical impacts.

  • Reflecting on your own values and culture and how they affect your attitudes, biases, preconceptions, and nursing care.

  • Seeking to understand the cultural beliefs and practices of others.

  • Being aware of differences in therapeutic communication with different cultures (e.g., use of silence, eye contact).

  • Using an interpreter to communicate effectively with people.  

• Culturally Sensitive Nursing Care: Includes:

  • Using surnames as a first introduction (e.g., "#Hello my name is…").

  • Being authentic and honest.

  • Avoiding slang or derogatory terms.

  • Not making assumptions.

  • Respecting all beliefs, even if you do not agree.

  • Respecting support people.

  • Making an effort to gain trust, which can take time.

  • Asking if you are unsure of cultural practices.  

The Nursing Process

• Registered Nurse Standards for Practice: The Nursing and Midwifery Board emphasizes the importance of critical thinking, therapeutic relationships, assessment, and developing a plan for nursing practice.  

• Characteristics of the Nursing Process:

  • Cyclic and dynamic

  • Evidence-based

  • Goal-directed and person-centered (holistic)

  • Focused on problem-solving and decision-making

  • Interpersonal and collaborative

  • Systematic and uses critical thinking  

Assessing Phase of the Nursing Process

• Purpose: To establish a database of the patient’s responses to healthcare concerns or illness and their ability to manage health care needs.  

• Purpose of Nursing Assessment:

  • To find out about the client’s needs, health problems, and responses to these problems, related experiences, health practices, goals, values, lifestyle, and expectations of the healthcare system.

  • To identify and work with patient strengths.

  • To identify health risks, such as falling and pressure injury.

  • To inform an individualized plan of care.

  • To compare to previous data and evaluate the effectiveness of nursing care.  

• Data Collection: Involves gathering data that is:

  • Objective

  • Subjective  

• Sources of Data:

  • Primary source (the patient)

  • Secondary sources (family members, support persons, health care professionals, records, laboratory and diagnostic tests, and relevant literature).  

• Methods of Gathering Data:

  • Observing

  • Examining

  • Interviewing  

• Types of Data:

  • Subjective Data:

    • Data from the person’s point of view, including feelings, perceptions, and concerns.

    • Apparent only to the person affected.

    • Symptoms described by the patient, including feelings, beliefs, perceptions, and stress.

    • Example: “I have a pain in my stomach & it’s making me feel sick.”  

  • Objective Data:

    • Measurable data obtained through observation, physical examination, and laboratory or diagnostic testing.

    • Detectable by an observer.

    • Signs that can be seen, felt, heard, smelled, or measured.

    • Example: On palpation, the abdomen is firm & slightly distended. Pulse & blood pressure elevated compared to baseline data.  

• Sources of Data:

  • Primary: From the person.  

  • Secondary:

    • Family members

    • Support persons

    • Health care professionals

    • Records

    • Laboratory and diagnostic tests

    • Relevant literature  

• How to Gather Data:

  • Observation:

    • Vision: Overall appearance, skin color & lesions, signs of distress.

    • Smell: Body, body fluid, or breath odors.

    • Hearing: Lung & heart sounds, bowel sounds, ability to communicate, language spoken.

    • Touch: Skin temperature & moisture, muscle strength, pulse rate, lesions felt.  

  • Examining the Person:

    • Systematic data collection.

    • Use observation (look, listen, & feel).

    • Techniques used:

      • Inspection (looking)

      • Auscultation (listening)

      • Palpation (feeling)

      • Percussion (feeling & listening)  

  • Interviewing:

    • Planned communication or a conversation with a purpose.

    • Purposes:

      • To inform decision-making.

      • Often the first part of a comprehensive assessment.

      • Crucial in establishing rapport.

      • Foundation of a therapeutic relationship.

    • Identify problems and concerns.

    • Evaluate progress.

    • Approach:

      • Environment, seating, timing, language.

      • Combination of directive & non-directive approaches.

    • Questioning techniques: open, closed, probing, clarifying.

    • Active listening.  

• Nursing Assessment:

  • Involves a holistic health history, considering:

    • Physical, developmental, intellectual, emotional (psychological), social, cultural, spiritual, and functional health patterns.

  • Healthcare facilities use various forms & charts to guide nurses in gathering data, such as:

    • Patient admission form

    • Nursing history form

    • Observation charts

    • Risk assessment forms  

• Data Documentation:

  • Nurses record the person’s data to complete the assessment phase.

  • Data is recorded in a factual and accurate manner.

  • Subjective data is recorded in the person’s own words, using quotation marks.  

• Validate Data:

  • Important to ‘double-check’ or verify the information gathered to confirm it is accurate & factual.

  • Helps the nurse to:

    • Ensure assessment information is complete.

    • Ensure objective & subjective data are aligned.

    • Obtain additional information that may have been overlooked.

    • Avoid jumping to conclusions & focusing in the wrong direction.  

• Implications for Nursing Students:

  • Nursing students need to develop knowledge & skills in performing systematic & comprehensive nursing assessments.

  • Incomplete/inaccurate assessments can result in ‘problems’ being overlooked or making poor judgments about what is wrong with the patient.

  • Early detection & action saves lives.  

• Nursing Assessment and RN Standards for Practice:

  • Nursing interventions are performed following comprehensive & accurate assessments.

  • RNs conduct assessments that are sensitive to the needs of individuals.

  • RNs use a range of data-gathering techniques, including observation, interview, measurement, health history & assessment.

  • RNs collect physiological, psychological, spiritual, socio-economic & cultural data.

  • RNs establish therapeutic relationships & communicate effectively