Nursing Assessment and Diagnosis Flashcards
Overview of Nursing Assessment
Definition of Assessment: Nursing assessment is the systematic and continuous collection, analysis, validation, and communication of patient data.
Nature of Data: Data reflects how health functioning is enhanced by health promotion or compromised by illness or injury.
The Database: The database includes all pertinent patient information collected by the nurse and other healthcare professionals. This comprehensive database enables the nurse to partner with patients to develop an effective and inclusive care plan.
Nursing Process Context: Assessment is the foundational step that leads into diagnosis, which is followed by outcome identification and planning, implementation, and finally, evaluation.
Learning Objectives for Assessment
After completing the study of assessment, the following goals should be achieved:
Define and describe the purpose of five types of nursing assessments.
Explain the relationship between nursing assessment and medical assessment.
Differentiate between objective and subjective data.
Identify five sources of patient data useful to the nurse.
Describe the purpose of nursing observation, interview, and physical assessment.
Obtain a nursing history using effective interviewing techniques.
Plan patient assessments by identifying assessment priorities and structuring the data to be collected systematically.
Identify common problems encountered in data collection, noting their possible causes.
Explain when data need to be validated and several ways to accomplish this.
Describe privacy, confidentiality, and professionalism issues related to patient assessment and data storage.
Describe the importance of knowing when to report significant patient data and of proper documentation.
Obtain and document purposeful, prioritized, complete, systematic, accurate, and relevant patient data in a standard format.
Critical Thinking Activities Linked to Assessment
Assessing Systematically and Comprehensively: This is required to identify both nursing and medical concerns.
Detecting Bias and Determining Credibility: Identifying bias and validating the reliability of information sources is essential.
Distinguishing Findings: Nurses must distinguish normal from abnormal findings and identify the risks for abnormal findings.
Making Judgments: Determining the significance of data and distinguishing relevant from irrelevant data.
Identifying Inconsistencies: Identifying assumptions, checking accuracy and reliability, and recognizing missing information.
Characteristics of Nursing Assessments
Purposeful: Every assessment must have a clear reason for being conducted.
Prioritized: Data collection should focus on the most urgent needs first.
Complete: All necessary data must be gathered to build a thorough database.
Systematic: Following a structured approach to ensure nothing is missed.
Factual and Accurate: Data must be objective and true to the patient's state.
Relevant: Focusing on data that pertains to the patient's health status and goals.
Recorded in a Standard Manner: Documentation must follow institutional protocols.
Types of Nursing Assessments
Initial Comprehensive Assessment:
Performed shortly after admittance to the hospital.
Purpose: To establish a complete database for problem identification and care planning.
Scope: Collects data on all aspects of the patient's health.
Focused Assessment:
May be performed during the initial assessment or as part of routine ongoing data collection.
Purpose: To gather data about a specific problem already identified, or to identify new or overlooked problems.
Quick Priority Assessments (QPA):
Short, focused, prioritized assessments completed to gain the most important information needed first.
Purpose: To flag existing problems and risks.
Emergency Assessment:
Performed when a physiologic or psychological crisis presents.
Purpose: To identify life-threatening problems.
Time-Lapsed Assessment:
Performed to compare a patient's current status to baseline data obtained earlier.
Purpose: To reassess health status and make necessary revisions in the care plan.
Triage Assessment:
A screening assessment to determine the extent and severity of patient problems and recommend appropriate follow-up.
Can be completed on the phone or in person.
Requires highly specialized nursing knowledge and clinical reasoning skills.
Community and Special Population Assessments: Focused on the health of larger groups or specific demographics.
The Nursing History and Interview
Purpose of Nursing History: Captures and records the uniqueness of the patient. It includes:
Profile and reason for seeking care.
Usual health habits and cultural considerations.
Current state of health, medications, and allergies.
Perception of health status.
Developmental, family, environmental, and psychosocial history.
Expectations of nursing and educational needs.
Personal resources and potential for injury.
Four Phases of a Nursing Interview:
1. Preparatory Phase: Preparation before meeting the patient.
2. Introduction: Establishing rapport and explaining the purpose.
3. Working Phase: Gathering the bulk of the subjective data.
4. Termination: Summarizing the interview and clarifying the next steps.
Establishing Assessment Priorities
Health Orientation: Tailoring the assessment to the patient's perspective on health.
Developmental Stage: Ensuring the assessment is age-appropriate.
Culture: Considering cultural beliefs and practices.
Need for Nursing: Identifying the specific nursing care required.
Medical vs. Nursing Assessments
Medical Assessments: These target data pointing to pathologic conditions (diagnosing the disease).
Nursing Assessments: These focus on the patient's response to health problems (how the disease or life process affects the person).
Objective vs. Subjective Data
Objective Data (Signs):
Definition: Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them.
Examples: Elevated temperature, skin moisture, vomiting.
Subjective Data (Symptoms):
Definition: Information perceived only by the affected person.
Examples: Pain experience, feeling dizzy, feeling anxious.
Sources of Patient Data
The patient (primary source).
Family and significant others.
Patient record (medical history, physical examination, progress notes).
Consultations and reports of laboratory or diagnostic studies.
Reports of therapies by other healthcare professionals.
Nursing and other healthcare literature.
The Skill of Nursing Observation
Determines current physical and emotional responses.
Determines the patient's current ability to manage care.
Determines the immediate environment and its safety.
Determines the larger environment (hospital or community).
Nursing Physical Assessment
Purposes:
Appraisal of health status.
Identification of health problems.
Establishment of a database for nursing interventions.
Methods:
Inspection: Deliberate, purposeful observations performed in a systematic manner.
Palpation: Use of the sense of touch to assess skin temperature, turgor, texture, moisture, and internal vibrations.
Percussion: Striking one object against another to produce sound to assess internal structures.
Auscultation: Listening with a stethoscope to sounds produced within the body.
Verification and Validation of Data
When to Verify: If there is a discrepancy between what the person says and what the nurse observes, or if the data lack objectivity.
Methods to Validate Inferences:
Perform a physical examination using proper equipment and procedure.
Use clarifying statements.
Share inferences with other team members.
Check findings with research reports.
Compare cues to a knowledge base of normal function.
Check the consistency of cues.
Problems Related to Data Collection
Inappropriate organization of the database.
Omission of pertinent data.
Inclusion of irrelevant, duplicate, erroneous, or misinterpreted data.
Failure to establish rapport and partnership.
Recording an interpretation of data rather than the observed behavior.
Failure to update the database.
Privacy, Confidentiality, and Professionalism
A primary ethical responsibility is safeguarding patient privacy.
Compliance with the Health Insurance Portability and Accountability Act (HIPAA) is mandatory.
The American Nurses Association (ANA) and National Council of State Boards of Nursing (NCSBN) provide guidelines on social media use for nurses.
Documentation Guidelines
Immediately report critical changes in health status verbally.
Record the initial database on the day of admission (digitally or in ink).
Summarize data concisely and comprehensively.
Use good grammar and standard medical abbreviations.
Use the patient's own words whenever possible (using quotation marks).
Avoid nonspecific terms (e.g., "good," "fair") subject to individual interpretation.
Introduction to Diagnosing and Problem Identification
Definition: The second step of the nursing process where the nurse interprets and analyzes patient data, identifies strengths and problems, and formulates nursing diagnoses.
Purposes of the Diagnosing Step:
1. Identify how an individual, group, or community responds to actual or potential health and life processes.
2. Identify factors that contribute to or cause health problems (etiologies).
3. Identify resources or strengths the patient can draw on to prevent or resolve problems.
Diagnostic Reasoning and Clinical Reasoning
Clinical Reasoning Processes: Includes analyzing, synthesizing, reflecting, and drawing conclusions.
Key Activities:
Creating a list of suspected problems/diagnoses.
Ruling out similar problems.
Naming actual and potential problems and clarifying causes.
Determining risk factors.
Identifying resources and areas for health promotion.
Nursing Concerns (Alfaro-LeFevre, 2014):
Recognizing safety and infection risks immediately.
Identifying human responses—how signs, symptoms, and treatments impact the patient's life.
Promoting independence and quality of life.
Anticipating complications and initiating urgent interventions without waiting for a final diagnosis if immediate treatment is signaled.
Predict, Prevent, Manage, and Promote (PPMP) Model
Predict: Anticipate common and dangerous complications of known problems.
Prevent/Manage: Take immediate action to prevent complications or manage them if they occur.
Risk Factors: Look for evidence of risk factors even if a problem isn't present; aim to reduce or control them.
Promote: Ensure safety, learning needs, optimum function, and independence.
Types of Diagnoses and Comparison
Nursing Diagnosis: Describes patient problems that nurses can treat independently. Focuses on unhealthy responses to health and illness; can change day to day.
Medical Diagnosis: Identifies diseases; directs the primary treatment by physicians or advanced practice nurses. Remains the same as long as the disease is present.
Collaborative Problems: Managed using both physician-prescribed and nursing-prescribed interventions.
Steps of Data Interpretation and Analysis
Recognizing Significant Data: Comparing data to established standards.
Recognizing Patterns or Clusters: Grouping related cues.
Identifying Strengths and Problems: Determining what the patient does well and where help is needed.
Identifying Potential Complications.
Reaching Conclusions: Determining if there is no problem, a possible problem, an actual nursing diagnosis, or a problem other than nursing diagnosis.
Partnering with the Patient and Family.
Formulation of Nursing Diagnosis Statements
Nursing diagnoses are often written as three-part statements (Problem, Etiology, Defining Characteristics).
Problem: Identifies what is unhealthy about the patient (the need for change). This suggests patient outcomes.
Etiology (Related To - R/T): Identifies factors maintaining the unhealthy state or contributing factors. This suggests appropriate nursing measures.
Defining Characteristics (As Evidenced By - AEB): Subjective and objective data (cues) that signal the existence of the problem.
Example Analysis from Table 15-3:
Problem: Bathing self-care deficit.
Etiology: Related to () fear of falling in the tub and obesity.
Defining Characteristics: As evidenced by () strong body and urine odor, unclean hair, and patient statement: "I'm afraid I'll fall in the tub and break something." Recorded physical data includes height and weight: .
Two-part statement: "Bathing self-care deficit R/T fear of falling in tub and obesity."
Three-part statement: "Bathing self-care deficit R/T fear of falling in tub and obesity, AEB strong body and urine odor, unclean hair, statement of fearing fall in tub, and height and weight: ."
Validating Nursing Diagnoses
Nurses should ask the following questions to validate a diagnosis:
Is the patient database sufficient, accurate, and supported by nursing research?
Does the synthesis of cues demonstrate a pattern?
Are the data used characteristic of the defined health problem?
Is the diagnosis based on scientific nursing knowledge and clinical expertise?
Can the diagnosis be prevented, reduced, or resolved by independent nursing action?
Is my confidence above that others would reach the same conclusion?
Documentation and Electronic Health Records (EHR)
View ongoing risks and problems identified by the team.
Document new diagnoses based on findings.
Facilitate communication of actual problems across the healthcare team.
Use diagnoses to set mutual goals with the patient.
Document when nursing diagnoses are resolved.
Common Errors in Writing Nursing Diagnoses
Premature Diagnoses: Based on an incomplete database.
Erroneous Diagnoses: Resulting from an inaccurate database or faulty analysis.
Routine Diagnoses: Failure to tailor data collection to the unique needs of the patient.
Errors of Omission: Failing to identify a problem that is present.
Questions & Discussion
Question (Assessment): True or False: Most health care institutions establish a minimum data set that specifies the information that must be collected from every patient and uses a structured assessment form to organize or cluster these data. * Answer: True.
Question (Diagnostic Steps): A nurse decides that a patient has a possible problem with high blood pressure. During which step of data interpretation would this most likely be determined? * Options: A. Recognizing significant data, B. Recognizing patterns or clusters, C. Identifying strengths and problems, D. Reaching conclusions. * Answer: D. Reaching conclusions.
Question (Risk Diagnosis): True or False: The nursing diagnosis "risk for impaired skin integrity" is an example of a correctly written risk diagnosis. * Answer: True (Note: Risk diagnoses do not have an AEB/defining characteristic section because the problem has not occurred yet).