HA LEC (PRELIM)

• Nursing Process: ADPIE

  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation
• Standard 1 of Nursing Scope and Standards of Practice: The registered nurse collects comprehensive data pertinent to the patient's health or situation
• To accomplish this, the registered nurse:

  • Collects data in a systematic and ongoing process
  • Involves the patient, family, other health care providers, and environment in holistic data collection
  • Prioritizes data collection activities based on the patient's immediate condition or anticipated needs
• Standard 2 of Nursing Scope and Standards of Practice: The registered nurse analyzes the assessment data to determine the diagnoses or issues
• To accomplish this, the registered nurse:

  • Derives the diagnosis or issues based on assessment data
  • Validates the diagnoses or issues with the client, family, and other healthcare providers
  • Documents diagnoses or issues in a manner that facilitates the determination of expected outcomes and plan
• The nurse's role in health assessments includes:

  • Forensic nursing requiring extensive focused assessments and development of nursing diagnoses
  • Acute care nurses performing focused assessments and developing comprehensive care plans with a multidisciplinary team
  • Critical care outreach nurses needing enhanced assessment skills for critically ill clients outside the intensive care environment
  • Ambulatory care nurses assessing and screening clients for physician referrals
  • Home health nurses making independent nursing diagnoses and referrals for collaborative problems
• • Public health nurses assessing the needs of communities
  • School nurses monitoring the growth and health of children
  • Hospice nurses assessing the needs of terminally ill clients and their families
• In all settings, nurses increasingly document and retrieve assessment data through sophisticated computerized information systems

  • Nursing health assessment courses with informatics content are becoming common in baccalaureate programs
• Assessment is the first and most critical phase of the nursing process

  • Precedes the other phases in the formal nursing process
  • Ongoing and continuous throughout all phases of the nursing process
  • Involves analyzing and synthesizing data, making judgments about the effectiveness of nursing interventions, and evaluating client care outcomes
• Comprehensive health assessment consists of both a health history and physical examination

  • Purpose is to collect holistic subjective and objective data to determine a client's overall level of functioning for professional clinical judgment
  • Nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the client - holistic data collection
• Types of Health Assessment:

  • Initial comprehensive assessment
  • Ongoing or partial assessment
  • Focused or problem-oriented assessment
  • Emergency assessment
• Initial Comprehensive Assessment:

  • Collection of subjective data about the client's health perception, past health history, family history, and lifestyle
  • Objective data gathered during a step-by-step physical examination
  • Regardless of who collects the data, a total health assessment is needed when the client first enters a health care system to establish baseline data
• Ongoing or Partial Assessment:

  • Data collection that occurs after the comprehensive database is established
  • Consists of a mini-overview of the client's body systems and holistic health patterns
  • Reassessed to determine changes from baseline data and detect new problems
  • Frequency is determined by the acuity of the client
• Focused or Problem-Oriented Assessment:

  • Does not replace the comprehensive health assessment
  • Performed when a comprehensive database exists for a client with a specific health concern
  • Consists of a thorough assessment of a particular client problem
• Emergency Assessment:

  • Very rapid assessment performed in life-threatening situations such as choking, cardiac arrest, or drowning
  • Immediate assessment is needed to provide prompt treatment
• Immediate assessment is needed to provide prompt treatment
• Evaluation of the client’s airway, breathing, and circulation (ABCs) when cardiac arrest is suspected
• During assessment, the major concern is to determine the status of the client’s life-sustaining physical functions
• Steps of Health Assessment:

  • Collection of subjective data
  • Collection of objective data
  • Validation of data
  • Documentation of data
• Preparing for the Assessment:

  • Review client’s medical record (if available)
  • Obtain background information such as age, sex, religion, educational level, and occupation
  • Validate information with the client and be prepared to collect additional data
  • Educate yourself about the client’s diagnoses or tests performed
  • Take a minute to reflect on your own feelings regarding your initial encounter with the client
  • Obtain and organize materials needed for the assessment
• Collecting Subjective Data:

  • Sensations or symptoms
  • Feelings
  • Perceptions
  • Desires
  • Preferences
  • Beliefs
  • Ideas
  • Values
  • Personal information
  • Major areas of subjective data include biographical information, history of present health concern, family history, health and lifestyle practices
• Collecting Objective Data:

  • Examiner directly observes objective data such as physical characteristics, body functions, appearance, behavior, measurements, and results of laboratory testing
  • General observation and physical examination techniques like inspection, palpation, percussion, and auscultation
  • Objective data can also be obtained from the client’s medical/health record, other health care team members, or family
• Validating Assessment Data:

  • Crucial part of assessment to ensure all relevant data have been collected and prevent documentation of inaccurate data
• Documenting Data:

  • Important step in the assessment process
  • Forms the database for the entire nursing process and provides data for all other members of the health care team
  • Thorough and accurate documentation is vital for valid conclusions
• Nursing Diagnosis:

  • Analysis of data is the second phase of the nursing process
  • Purpose is to arrive at conclusions about the client’s health
  • Analyze and synthesize data to determine nursing concerns, collaborative concerns, and referrals
• Process of Data Analysis:

  1. Identify abnormal data and strengths
  2. Cluster the data
  3. Draw inferences and identify problems
  4. Propose possible nursing diagnoses
  5. Check for defining characteristics of those diagnoses
  6. Confirm or rule out nursing diagnoses
  7. Document conclusions
• Collecting Subjective Data: The Interview and Health History:

  • Sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, personal information elicited and verified only by the client
  • Interviewing involves establishing rapport, gathering information on the client’s statuses, and reviewing the medical record
• Communication During Interview:

  • Nonverbal communication includes appearance, demeanor, facial expression, attitude, silence, and listening
  • Verbal communication includes open-ended questions to elicit client’s feelings and perceptions
• • Well-Placed Phrases like "um-hum" or "I agree" encourage the client to continue
  • Inferring involves gathering more data from what the client tells you and what you observe
  • Providing Information to the client as questions and concerns arise
• Verbal Communication during Interview:

  • Open-ended questions are used to explore feelings and thoughts, like asking "How does this make you feel?"
  • Closed-ended questions are used to obtain specific information with one or two-word responses, like "When did your headache start?"
  • Laundry List involves providing a list of words for the client to choose from in describing symptoms or conditions
  • Rephrasing helps clarify information the client stated, like restating "You are thinking that you have a serious illness?"
• Special Considerations During the Interview:

  • Gerontologic Variations in Communication include assessing hearing acuity, speaking clearly, and showing respect
  • Cultural Variations in Communication involve reluctance to reveal personal information and different perceptions of disease and illness
  • Emotional Variations in Communication include clients feeling scared, anxious, angry, or depressed
• Complete Health History:

  • Provides a focus for the physical examination
  • Assists in identifying areas of strength and limitation in the individual's lifestyle and health status
  • Includes sections like Biographic Data, Reasons for seeking health care, Personal health history, and more
  • Subjective data is gathered through interviewing to collect information verified by the client
• Preparing the Physical Setting:

  • Ensure a comfortable, warm room temperature
  • Provide a private area free of interruptions
  • Have adequate lighting for examination
  • Use a firm examination table or bed at a suitable height
  • Prepare oneself by handwashing, wearing gloves, mask, and protective eye goggles
• Approaching and Preparing Client:

  • Establish the nurse-client relationship before the physical examination
  • Respect the client's desires and requests
  • Begin with less intrusive procedures like measuring temperature, pulse, blood pressure, height, and weight
• Physical Examination Techniques:

  • Include Inspection, Palpation, Percussion, and Auscultation
• Position Descriptions:

  • Standing: assess posture, balance, gait
  • Prone: used for assessing hip joint and back
  • Knee-Chest: assess rectum
  • Lithotomy: used for examining female genitalia, reproductive tracts, and rectum
• Validating and Documenting Data:

  • Validation is confirming that collected data are reliable and accurate
  • Failure to validate data may lead to diagnostic errors
  • Documentation promotes effective communication among health team members and provides a foundation for client care