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8/10/2019 Chapter 12 Assessing
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Copyright 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 12Assessing
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Copyright 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Four Types of Nursing Assessments
Comprehensive initial
Focused
Emergency
Time-lapsed
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Assessing: The Primary Source ofInformation Is the Patient
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Comprehensive Initial Assessment
Performed shortly after admittance to hospital
Performed to establish a complete database for problemidentification and care planning
Performed by the nurse to collect data on all aspects ofpatients health
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Emergency Assessment
Performed when a physiologic or psychological crisispresents
Performed to identify life-threatening problems
Performed by the nurse to gather data about the life-threatening problem
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Time-Lapsed Assessment
Performed to compare a patients current status tobaseline data obtained earlier
Performed to reassess health status and make necessaryrevisions in plan of care
Performed by the nurse to collect data about currenthealth status of patient
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Establishing Assessment Priorities
Health orientation
Developmental stage
Need for nursing
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Medical vs. Nursing Assessments
Medical assessments
Target data pointing to pathologic conditions
Nursing assessments
Focus on the patients response to health problems
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Objective Data vs. Subjective Data
Objective data
Observable and measurable data that can be seen,heard, or felt by someone other than the personexperiencing them
e.g., elevated temperature, skin moisture, vomiting
Subjective data
Information perceived only by the affected person
e.g., pain experience, feeling dizzy, feeling anxious
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Characteristics of Data
Purposeful
Complete
Factual and accurate
Relevant
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Sources of Data
Patient
Family and significant others
Patient record
Other healthcare professionals
Nursing and other healthcare literature
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The Skill of Nursing Observation
Determines the patients current responses (physical andemotional)
Determines the patients current ability to manage care
Determines the immediate environment and its safety
Determines the larger environment (hospital orcommunity)
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Four Phases of a Nursing Interview
Preparatory phase
Introduction
Working phase
Termination
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Purpose of a Nursing Physical Assessment
Appraisal of health status
Identification of health problems
Establishment of a database for nursing intervention
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Successful Interview Techniques
Focus on the patient during the interview
Listen to the patient attentively
Ask about patients main problem first
Pose questions and comments in appropriate manner
Avoid comments and questions that impede
communication
Use silence and touch appropriately
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Type of Questions Used in Interviews
Closed questionselicit specific information
Open-ended questionsallow the patient to verbalizefreely
Reflective questionsencourage patient to elaborate onthoughts and feelings
Direct questionsvalidate or clarify information
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Collaborating Members of the HealthcareTeam
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Problems Related to Data Collection
Inappropriate organization of the database
Omission of pertinent data
Inclusion of irrelevant or duplicate data, erroneous ormisinterpreted data
Failure to establish rapport and partnership
Recording an interpretation of data rather than observedbehavior
Failure to update the database
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When to Verify Data
When there is a discrepancy between what the person issaying and what the nurse is observing
When the data lack objectivity
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Validating Inferences
Performing a physical examination using properequipment and procedure
Using clarifying statements
Sharing inferences with other team members
Checking findings with research reports
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Documentation of Data
Enter initial database into computer or record in ink ondesignated forms the same day patient is admitted
Summarize objective and subjective data in concise,comprehensive, and easily retrievable manner
Use good grammar and standard medical abbreviations
Whenever possible, use patients own words
Avoid non-specific terms subject to individualinterpretation or definition
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Question
Tell whether the following statement is true or false.
A nursing assessment duplicates a medical assessmentby focusing on the patients responses to the healthproblem.
A. True
B. False
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Answer
Answer: B. False
A nursing assessment does not duplicate a medicalassessment, rather it focuses on the patients responsesto the health problem.
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Question
Which one of the following assessments would beperformed on a patient to gather data about his
previously diagnosed liver cancer?A. Initial assessment
B. Focused assessment
C. Emergency assessment
D. Time-lapsed assessment
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Answer
Answer: B. Focused assessment
Rationale:
In a focused assessment the nurse gathers data about acondition that has already been diagnosed.
An initial assessment is performed shortly after thepatient is admitted to a healthcare agency or service.
When a physiologic or psychological crisis presents, thenurse performs an emergency assessment.
A time-lapsed assessment compares a patients currentstatus to baseline data obtained earlier.
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Question
Tell whether the following statement is true or false.
Most healthcare institutions establish a minimum data setthat specifies the information that must be collected fromevery patient and uses a structured assessment form toorganize or cluster these data.
A. True
B. False
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Answer
Answer: A. True
Most healthcare institutions establish a minimum data setthat specifies the information that must be collected fromevery patient and uses a structured assessment form toorganize or cluster these data.
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Question
Tell whether the following statement is true or false.
A patient rates his pain as a 7 on a pain rating scale.This rating is considered to be objective data.
A. True
B. False
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Answer
Answer: B. False
A patient rates his pain as a 7 on a pain rating scale.
This rating is considered to be subjective data.
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Question
In which of the following phases of the nursing interviewdoes the nurse gather all the information needed to form
the subjective database?A. Preparatory phase
B. Introduction
C. Working phase
D. Termination
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