prelims

• The term nursing process was used by Hall (1955), Johnson (1959), Orlando (1961), Wiedenbach (1963), ANA (1973)
• Nursing process is a systematic and rational method of planning and providing individualized nursing care
• Characteristics of a nursing process:

  • Cyclic and dynamic in nature
  • Client-centered
  • Focus on problem-solving and decision-making
  • Different but parallel to the process used by physicians
  • Interpersonal and collaborative style
  • Universally applicable
  • Use of critical thinking – logic, intuition, and creativity
• Critical thinking in nursing:

  • Discipline-specific
  • Reflective reasoning process
  • Purpose: Guides a nurse in generating, implementing, and evaluating approaches for dealing with client care and professional concerns
• Components of critical thinking:

  • Critical analysis
  • Inductive and deductive reasoning
  • Making valid inferences
  • Differentiating facts from opinions
  • Evaluating the credibility of information
  • Clarifying concepts
  • Recognizing assumptions
• Health assessment is a comprehensive assessment of one's health status

  Primary components:

  • Nursing Health History
  • Physical Assessment
• Purposes of health assessment:

  • To obtain baseline data
  • To supplement, confirm, or refute data
  • To establish nursing diagnoses and plans of care
  • To evaluate physiological outcomes of health care
  • To make clinical judgments
  • To identify areas for health promotion and disease prevention
• Assessment is a systematic and continuous collection, organization, validation, and documentation of data

  Purpose: Establish a database

  Activities:

  • Collecting Data
  • Organizing Data
  • Validating Data
  • Documenting Data
• Collection of data includes:

  • Nursing health history
  • Physical assessment
  • Primary care provider's history
  • Physical examination
  • Results of laboratory and diagnostic tests

  Types of data:

  • Subjective data (symptoms)
  • Objective data (signs)

  Sources of data:

  1. Primary – client

  2. Secondary – family, support persons, other health professionals, medical

  3. Records and Reports, Laboratory and Diagnostic, Relevant literature

  Data collection methods:

  • Observation
  • Interview
• 2 Approaches to interview:

  A. Directive: Nurse establishes the purpose of the interview and controls the interview

  B. Nondirective or rapport-building

  Types of interview questions:

  1. Closed-Ended Questions

  2. Open-Ended Questions

  3. Neutral Questions

  4. Leading Questions

  Factors to be considered during the interview:

  • Time
  • Place
  • Seating arrangement
  • Distance
  • Language

  Stages of interview:

  1. Opening or introduction

  2. Body or development

  3. Closing
• Examination:

  • Physical examination or Physical assessment is a systematic data collection method that uses observation

  Physical Examination (IPPA Technique):

  • Inspection
  • Palpation
  • Percussion
  • Auscultation
  • Head-to-toe Approach (Cephalocaudal)
• Organizing data:

  • Nurse uses a written (or computerized) format that organizes the assessment data systematically in the form of:
  • Nursing health history
  • Nursing assessment
  • Nursing database form

  Assessment format:

  Conceptual Models / Frameworks

  • Gordon's Functional Health Pattern
  • Orem's Self-Care Model
  • Roy's Adaptation Model
  • Wellness Model
  • Non-nursing Models
  • Body Systems Model
  • Maslow's Hierarchy of Needs
  • Freud's Developmental Theories
• Validation of data:

  • Act of "double-checking" or verifying data to confirm that it is accurate and factual
  • Complete, factual, accurate
• Documenting data: Recording of data

  • Must be accurate
  • Factual manner and not as interpreted by the nurse
  • Subjective data - verbatim
• Health assessment in nursing practice:

  Types of health assessment:

  1. Initial Comprehensive Assessment

  2. Ongoing or Partial Assessment

  3. Focused or Problem-Oriented Assessment

  4. Emergency Assessment

  1. Initial Comprehensive Assessment includes the client's:

  • Perception of health
  • Past health history
  • Lifestyle and health practices
  • Objective and subjective data
• 2. Ongoing or Partial Assessment:

  • Data collection that occurs after a comprehensive database is established
  • A brief reassessment of the client's body system is performed to detect any new problems
  • Usually performed whenever the nurse or another health care professional has an encounter with the client
• 3. Focused or Problem-Oriented Assessment:

  • Done when a patient comes to the health care agency with a specific health concern
  • Thorough assessment of a particular problem and does not cover areas not related to the problem
  • Does not replace the comprehensive health assessment
• 4. Emergency Assessment:

  • Very rapid assessment performed in life-threatening situations
  • Immediate diagnosis is needed to provide prompt treatment
  • Major concern: determine the status of the client's life-sustaining physiological functions

  Example: Evaluation of client's ABC (Airway, Breathing, Circulation) when cardiac arrest is suspected
• Frameworks in health assessment:

  Framework:

  • A basic structure underlying a process, system, concept, or text

  Types of frameworks:

  1. Functional Health Framework

  2. Cephalocaudal Framework

  3. Body Systems Framework
• Critical thinking in health assessment:

  • A purposeful, goal-directed thinking process that strives to problem solve patient care issues through the use of clinical reasoning
  • It combines logic, intuition, and creativity
• Clinical reasoning:

  • A disciplined, creative, and reflective approach used together with critical thinking
  • Purpose: Establish potential strategies to assist patients in reaching their desired health goals
• Components of critical thinking:

  1. Interpretation

  2. Analysis

  3. Inference

  4. Explanation

  5. Evaluation

  6. Self-regulation
• 1. Interpretation:

  • Decode hidden messages, clarify the meaning of the information, categorize the information
  • Nursing Practice Application: Be systematic in data collection. Look for patterns to categorize data you are uncertain about
• 2. Analysis:

  • Ideas and data presented, identifies any discrepancies, and reflects on the reason for the discrepancies
  • Nursing Practice Application: Be open-minded as you look at information about a client. Do not make careless assumptions. Look for patterns to categorize data you are uncertain about
• 3. Inference:

  • Speculates, derives, or reasons a specific premise based on information and assumptions obtained from the patient
  • Nursing Practice Application: Look at the meaning and significance of findings. Are there relationships between findings? Does the data about the client help you determine that a problem exists?
• 4. Explanation:

  • Requires that the conclusions drawn from the inferences are cored and can be justified
  • Nursing Practice Application: Support your findings and conclusions. Use knowledge to select strategies you use in the care of clients
• 5. Evaluation:

  • Examines the validity of the information and hypothesis; this leads to a final conclusion that can be implemented
  • Nursing Practice Application: Look at all situations objectively. Use criteria to determine results of nursing actions. Reflect on your own behavior
• 6. Self-regulation:

  • Key component to the critical thinking process; the nurse reflects on the critical thinking skills that were employed and determines which techniques were effective and which were problematic
  • Nursing Practice Application: Reflect on your experience. Identify in what way you can improve your performance
• Nurses' role in health assessment:

  • Nurses' role: Dynamic

  Factors influencing roles of nurses:

  • Role Expansion – New Roles
  • Computerized Information Systems
  • Education vs Economy: Supply vs Demand
  • Educational Costs and Focus on Primary Care
  • Aging population
  • Mental health issues
  • HMOs
• Past:

  • Nurses relied on their natural senses
  • The client's face and body would be observed for changes in color, temperature, muscle strength, use of limbs, body output, and degrees of nutrition and hydration (Nightingale, 1992)
• Health assessment across time:

  • 1901 - Journal Records: examples of independent nursing practice: inspection, palpation, and auscultation have been recorded
  • 1901-1938 - American Journal of Nursing: RNs doing gastrointestinal palpation, testing cranial nerve function and examination of children in school systems
  • 1930s - American Journal of Public Health: routine client and home inspection by PHN
  • 1970s - provision of primary health services and expansion in conduct of health history
• 1930s: Routine client and home inspection by Public Health Nurses (PHN)
• 1970s: Provision of primary health services and expansion in the conduct of health histories and physical/psychological assessments
• 1980s: Acute care nurses employed the "primary care" method of delivery of care
• 1990 - Present Priorities:

  • Downsizing, budget cuts, and restructuring in the 1990s
  • Critical pathways or care maps emerged
  • Demand for documentation increased
  • Advanced Practice Nurses (APNs) became prominent
  • Reimbursement Issues arose
  • Diagnosis-Related Groups (DRGs) implemented
  • Health care coverage plans such as Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) became prevalent
• 21st Century Emerging Roles and Its Impact on Health Assessment:

  1. Forensic

  2. Acute Care

  3. Ambulance Care

  4. Critical Care Outreach

  5. Ambulatory Care

  6. Home Health

  7. Public Health

  8. School

  9. Hospice
• Telemedicine and Telehealth:

  • Telemedicine/Telehealth involves the delivery of health-care services across a distance utilizing Information and Communication Technology (ICT)
  • Telehealth encompasses all promotive, preventive, and curative care
  • Telehealth Nursing involves the delivery of nursing services across a distance utilizing ICT
  • Types of technology-based services include video conferencing, digital transmission, remote patient monitoring (RPM), and mobile health
  • Advantages of Telehealth Nursing:
  • Patients manage chronic conditions better
• • Patients have increased access to care
  • Patients avoid risks and save time and money
  • Nurses have more flexibility
  • Disadvantages of Telehealth Nursing:
  • Some visits need to be in person
  • Some patients experience barriers to care
  • Licensing laws limit the service area
  • Reimbursement is inconsistent
• Guidelines in an Effective Interview:

  • Interview is a method of gathering information from the client
  • Skills required for a good interview include professional, interpersonal, and interviewing skills
  • Phases of the interview: Pre-introductory, Introductory, Working, Summary and Closing
  • Components of the interview include establishing rapport, gathering information on the client's status
• Communication:

  • Types of communication: Non-verbal and Verbal Communication
  • Non-verbal communication is as important as verbal communication
  • Verbal communication includes open-ended questions, close-ended questions, and other techniques
  • Special considerations for communication based on age, culture, and emotional variation