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Heal th Assessment and theNurse

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Outcomes

Define assessment. Discuss assessment as part of the nursing process.

Discuss assessment, cognitive, psychomotor,

affective/interpersonal, and ethical skills.

Differentiate nursing from medical assessment.

(Continued)

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Outcomes

Identify the role of assessment in all levels ofpreventive health care.

Differentiate subjective and objective data.

Differentiate primary and secondary data sources.

Describe factors that affect communication.

(Continued)

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Outcomes

Discuss cultural effects on communication. Demonstrate various communication techniques.

Identify the phases of the interview.

Describe data collection methods.

Define the four techniques of physical assessment.

(Continued)

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Outcomes

Demonstrate the four techniques of physicalassessment.

Discuss methods used to validate assessment data.

Describe various methods to document assessment

findings.

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What Is Assessment?

A data collection process The first step in the Nursing Process

A continuous process

A method to establish a baseline

(Continued)

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Communicat ion

Nonverbal messages and touch

Vocal cues and paralinguistics: quality of voice,

inflection, tone, intensity, and speed

Action cues & kinetics: body movements, posture,

arm position, hand gestures, facial expression, eye

contact(Continued)

- is defined as a process of generatingand transmitting meaning and itincludes verbal and non verbalcommunication

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Communicat ion

Object cues: grooming, dress

Personal space: public, social, and personal

Cultural considerations

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Commun icat ion Techniques

Affirmation/ Facilitation- Acknowledge patient'sresponse

non-verbal gesturesuch as:nodding, or sitting up andleaning forward, encourage

patient to continue.

Verbal cuessuch as saying: ahha, go on, tell me more.

Silence- it allows pt to collect her/his

thoughts before responding

& help prevents hastyresponses that may beinaccurate.

- it gives you more time tothink and plan your

responses.

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Clarifying- if you are unsure or

confused about whatyour pt is saying,

rephrase what she/hesaid & then ask the ptto clarify.

Phrases Like:Let me see if i have this

right, or I want tomake sure i'm clear onthis, or I'm not surewhat you mean.

Restating- restating the pt's main idea shows

him that you are listening.- allows acknowledging pt's feeling

and encourages further discussion- it also helps clarify and validate

what your pt has said and may helpidentify teaching needs.

For example:

I take a water pill every day for my bloodpressure,your response might be, I see you take Lasix

every morning for your blood pressure.if the pt replies No, I take water pill every

morning,

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Active Listening- Pay attention- maintain eye contact- it conveys interest and

acceptance

Broad or general

Opening

- use open-ended questionssuch as: What wouldyou like to talk about?

Reflection- it allows you to acknowledge

your pt's feelings, encouraging

further discussion.- when your pt expresses a

thought or feeling, you echo itback, usually in a form ofquestion.

For example:I am so afraid of having surgery

your response:You're afraid of having surgery?

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Humor- it can be very therapeutic

when used in the rightcontext.

- it can reduced anxiety, helppts cope more effectively,put things into perspective,abd decrease socialdistance

Informing- giving information allows

your pt to be involved inhis/her healthcaredecuisions.

Redirecting- helps keep the communication

goal-directed.- it is especially useful if pt goes

off on tangentFor example:Getting back to what brought you to the

hospital

Focusing

- allows you to hone in on specificarea, encouraging furtherdiscussion

For example:

You said your mother & sister had breast cancer?or Do you do BSE, & have you ever had amammogram?

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Sharing Perceptions- you give your interpretation

of what has been said inorder to clarify things and

prevent misunderstanding.For example:You said you weren't upset, but you're

crying

Identifying Themes- may help your pt make a

connection & focus on themajor theme.

For example:

From what you've told me, it sounds likeevery time you were discharged from thehospital to home you had problem

Sequencing Events- helps her/him place the events, in

proper order- start at the beginning & work

through the event until the

conclusion.For example:

What happened before the problem started? Then

what happened? How did it end?

Suggesting

- presenting alternative ideas givespt options.- helpful if pt having difficulty

verbalizing his/her feelingsFor example:

I've tried so hard to lose weight, but I can't

Have you tried combining diet and exercise?

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Presenting Reality

- if the pt seems to beexaggerating or contradicting

the facts, help her/himreexamine what has already

been said & be more realistic.

For example:

I waited all day for someone to answer my

call lightAll day?

Summarizing- is useful at the conclusion of

a major section of the

interview.- it allows the pt to clarify any

miosconceptions you mayhave

For example:

Let me see if I have this correct; you came to

the hospital with chest pain, which startedan hour ago, after eating lunch.

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How You Communicate

Genuineness- be open, honest and sincere

- pt can detect a less-than-honest response or

inconsistencies between your verbal & non-

verbal behavior

Respect

- everyone should be respected as a person of worth & value

- you need to be non-judgemental

- you may not always agree with your pt's decisions or like or

approve of his/her behavior, but everyone needs to feelaccepted as a unique individual

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How You Commun icate

Empathy- is knowing what your pt means &

understanding how she/he feels

- showing empathy acknowledges your

pt's feelings; shows acceptance, care,and concern; and foster open

communication

- phrases that recognize your pt's

feeling help build a trusting

relationshipFor example:

That must have been very difficult for you

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What Is Assessment?

A systematic process

Identifies patients strengths and

limitations

Involves collecting, validating,

and clustering data

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Purpose of Assessment

Collect pertinent patient health status

data Identify abnormal findings

Identify patients strengths and coping

resources

(Continued)

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Purpose of Assessment

To collect date pertinent to the pt's

health status

To identify deviations from normal

To discover the pt's strengths and

coping resources

Pinpoint actual health problems

Identify risk factors for health

problems

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Ski l ls of Assessment

Cognitive Skills Psychomotor

Interpersonal/Affective Skills Ethical Skills

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Assessment Ski l ls

Cognitive Skills

Critical thinking

- is a complex thinking process that has been defined in

many ways; Critical thinking is reflective, reasonable thinking (Ennis,

1985).

It is not just doing, it is asking why?.

It involves inquiry, interpretation, analysis and synthesis.

(Continued)

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Assessment Ski l ls

Cognitive Skills

Clinical Decision Making

- as you collect data, you will make clinical

decisions as to its relevance.- look for cues and make inferences

(Continued)

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Assessment Skil ls

Problem-Solving Skills

Reflexive thinkingis automatic, without conscious

deliberation, and comes with experience.

Trial and erroris hit-or-miss thinkingrandom, notsystematic and inefficient.

Scientific methodis systematic, critical-thinking

approach to problem solving.

Intuitionis a problem-solving method that developsthrough experience, in which theory and practice are

intertwined.

(Continued)

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Assessment Ski l ls

Ethical Skills

Assessment is being responsible and accountable.

Responsible & accountable for practice

Patient advocate Respect patients rights

Assure confidentiality

AssignmentThe Code for Nurses in a short bond paper verdana 12.

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Difference Between Nursing & Medic ine

Nursings Goal

To diagnose and treat human responses to actual or

potential health problems- nursing's aim is to help the patient reach her/his optimal level of

wellness

Medicines Goal

To diagnose and treat disease

AssignmentThe NJPC's Element of Collaboration

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Levels o f Preven tive Care

Primary

To focus on health promotion and illness prevention

- example: health fairs, immunizations, and nutritional instructions.

Secondary

To focus on early detection, prompt intervention, and

health maintenance.

- it addresses acute health problems seen with inpatienthospitalization

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Levels o f Preven tive Care

Tertiary

To focus on rehabilitation and extended care

- pt's health status is generally more stable than in secondary

care, pt usually have a chronic illness.

Examples: Skilled Nursing care Facilities

Rehabilitative hospitals

long-term facilities

home care

and hospice

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Comprehensive Assessment- initial assessment- it is very thorough and includes a detailed health history

and physical examination.- examine the pt's qverall health status.

Focused Assessment- problem oriented and may be intial assessment or ongoing

assessment- is frequently performed on an ongoing basis to monitor

and evaluate the pt's progress, interventions, and responseto treatments

Types

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Assessment Data

Subjective

-Covert, not measurable

- reflects what the pt is experiencing & include

thoughts, belief, feelings, sensations, & perceptions- referred to as symptoms

Objective

- Overt, measurable

- referred to as signs: physical examination &

diagnostic studies.

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Primary Sourcespatient

Secondary Sources

anyone or anything aside from the patient, includingfamily members, friends, other healthcare providers,

and old medical records.

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Methods o f Data Col lect ion :

The nterview Is usually structured communication

intended to obtain subjective data Most effective when taking the health history

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The Interview Types of interviews:

Directive interviewsare structured with specific

questions & are controlled by the nurse

- require less time and are very effective

obtaining factual data.

Non-directive interviews

- are controlled by the patient

- require more time but are very effective at

eliciting the pt's perceptions and feeling.

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Types of questions:

Openpt perception, what brought you to thehospital? (non directive interviews)

Closedare often those that elicit a yes or noresponse Do you have pain? (directive

interview) Interviewing tips/pitfalls - assignment


Assignment interviewing Technique

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Interviewing tips/pitfalls Leading the patient

Biasing yourself

Letting family members answer

for patient Asking more than one question at

a time

Not allowing enough responsetime

Using medical jargon

Assuming rather than clarifying

and validating

Taking the patient's responses

personally

Methods of Data Col lec t ion :

Interviewing tips/pitfalls Feeling personally

uncomfortable

Using clichs

Offering false reassurance Asking persistent or probing

questions

Changing the subject

Taking thing literally

Giving advice

Jumping to conclusion

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Phases of the In terv iew

The Introductory Phase

Introduce self

Put patient at ease

Explain purpose of interview

Explain time frame

Reassure that the information collected is confidential

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Phases o f the In terv iew

The Working Phase

Data collection, structured

Longest phase

Listening is very crucial

The Termination Phase

End of interview Summarize & restate findings

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Observation

Entails deliberate use all of your senses

Look at patient and environment to detect anything

out of ordinary What data can you collect through observation?

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Inspection

Palpation

Percussion

Auscultation

Physical Assessment- it helps assess pt's health status & identify actual orpotential problem

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Validation- once you have collected the data, you need to validate them

to ensure their accuracy.

Organizing Data- after validating the assessment data, you need to organize

them.

- begin identifying pertinent dataany findings that are out

of norm and any findings that identify pt strengths- clustering relevant data gives meaning to the data, this will

be the basis for formulating nursing diagnoses for the pt


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Organ izing data

Several frameworks- it provides a way looking

at pt and the data.

Maslow's Hierarchy ofHuman Needs

-

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Organ izing data

Roy's Adaptation theory

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Gordon 's 11 Funct ional PatternsMarjorie Gordon (1987) proposed functional health patterns as a guide for establishing acomprehensive nursing data base.

Health Perception and Health Management- Data collection is focused on the person's perceived level of health and well-

being, and on practices for maintaining health.- Habits that may be detrimental to health are also evaluated, including smoking

and alcohol or drug use.- Actual or potential problems related to safety and health management may be

identified as well as needs for modifications in the home or needs forcontinued care in the home.

Nutrition and Metabolism

- Assessment is focused on the pattern of food and fluid consumption relative tometabolic need.

- The adequacy of local nutrient supplies is evaluated.- Actual or potential problems related to fluid balance, tissue integrity, and host

defenses may be identified as well as problems with the gastrointestinal

system.

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Gordon 's 11 Func t ional Patterns

Elimination- Data collection is focused on excretory patterns (bowel, bladder, skin).- Excretory problems such as incontinence, constipation, diarrhea, and urinary

retention may be identified.

Activity and Exercise- Assessment is focused on the activities of daily living requiring energy

expenditure, including self-care activities, exercise, and leisure activities.- The status of major body systems involved with activity and exercise is

evaluated, including the respiratory, cardiovascular, and musculoskeletalsystems.

Cognition and Perception- Assessment is focused on the ability to comprehend and use information and on

the sensory functions.

- Data pertaining to neurologic functions are collected to aid this process.

- Sensory experiences such as pain and altered sensory input may be identifiedand further evaluated.

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Sleep and Rest- Assessment is focused on the person's sleep, rest, and relaxation practices.- Dysfunctional sleep patterns, fatigue, and responses to sleep deprivation may

be identified.

Self-Perception and Self-Concept- Assessment is focused on the person's attitudes toward self, including identity,

body image, and sense of self-worth.- The person's level of self-esteem and response to threats to his or her self-

concept may be identified.

Roles and Relationships- Assessment is focused on the person's roles in the world and relationships with

others.

- Satisfaction with roles, role strain, or dysfunctional relationships may befurther evaluated.

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Sexuality and Reproduction

- Assessment is focused on the person's satisfaction or dissatisfaction withsexuality patterns and reproductive functions.

- Concerns with sexuality may he identified.

Coping and Stress Tolerance- Assessment is focused on the person's perception of stress and on his or her

coping strategies Support systems are evaluated, and symptoms of stress arenoted.

- The effectiveness of a person's coping strategies in terms of stress tolerance

may be further evaluated.

Values and Belief

- Assessment is focused on the person's values and beliefs (including spiritualbeliefs), or on the goals that guide his or her choices or decisions.

NANDA- Unitary Person Framework- organizes data based on the concept that a person is an open sy stem in

cons tant interact ion with th e environment.

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Data Collec t ion Pitfal ls

Omitting data -

Misinterpreting data

Hasty interpretation

Irrelevant data Failure to follow-up

Poor communication

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Prior i t iz ing Data

Primary or Top PriorityLife-threatening problems

Secondary

Require prompt attention to preventfurther progression or deterioration

Tertiary

Important, but do not require immediate

attention

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Document ing Data

Methods

SOAPIE

DAR

PIE

Narrative

Documentation tips

Documents

Chapter 01 HA