NCMA 111 (CU #2)

• Nursing Assessment is the first and most critical phase of the nursing process, where inadequate or inaccurate data collection can lead to incorrect nursing judgments
• Assessment is ongoing and continuous throughout all phases of the nursing process
• Data Collection involves gathering information about the health status of the client, analyzing and synthesizing that data, making judgments about the effectiveness of nursing interventions, and evaluating client care outcomes
• Types of Data in data collection:

  • Subjective Data: Symptoms or Covert Data, apparent only to the person affected
  • Objective Data: Signs or Overt Data, detectable by an observer and can be measured or tested
• Sources of Data include the client, support people like family members, friends, and caregivers, client records, health care professionals, and literature
• Data Collection Methods:

  • Observing: To gather data using the senses, noticing the data and selecting, organizing, and interpreting it
  • Interview: Planned communication or conversation with a purpose to get or give information, identify problems, evaluate change, teach, provide support, and provide counseling or therapy
• Phase of the Interview:

  • Pre-Introductory Phase: Nurse reviews the medical record before meeting with the client or relies on interview skills if a medical record is not established
  • Introductory Phase: Nurse explains the purpose of the interview, discusses the types of questions, explains the reasons for taking notes, assures confidentiality, and develops trust and rapport
  • Working Phase: Nurse elicits client's comments about major biographic data, reasons for seeking care, history of present health concern, and more
  • Summary and Closing Phase: Nurse summarizes information obtained during the working phase, identifies and discusses possible plans to resolve problems, and ensures all client concerns and questions are addressed
• Directive Interview is highly structured, controlled by the nurse, and elicits specific information using directive questions
• Types of Interview Questions:

  • Closed Questions: Answerable only by YES or NO, often used for patients who are highly stressed and have difficulty communicating
  • Open-Ended Questions: Invite clients to explore, elaborate, clarify thoughts or feelings, and are useful in eliciting attitudes and mental status
• Factors to Consider during the Interview:

  • Time: When the client is physically comfortable and free of pain
  • Place: Well-lighted, well-ventilated, free of noise and distractions
  • Language: Avoid medical jargon, use translators or interpreters
  • Culture: Consider beliefs associated with health and illness, caregiving, and treatment
• Things to Avoid during an Interview include leading the patient, biasing oneself, letting family members answer for the patient, asking more than one question at a time, and using medical jargon
• Examination:

  • Physical Examination is carried out systematically using a cephalocaudal (head-to-toe) approach
  • Screen Examination is a brief review of essential functioning of various body parts or systems
• Biographical data includes the patient's identity (name, address, phone number, gender), with the patient being the primary source of data and others as secondary sources
• A format summary for obtaining biographical data may include details like name, birth date, address, phone number, nationality, gender, marital status, religion, primary/secondary language, educational level, occupation, significant others, and provider of history (patient or other)
• Subjective data collection through interview and health history involves reasons for seeking health care, major health problems or concerns, feelings about seeking health care, fears, past experiences, chief complaint, history of present illness, past health history, family health history, lifestyle and health practices profile, psychosocial history, and factors influencing psychosocial health
• Psychosocial history assessment considers a person's ability to think, feel, act, and relate to others, cope with stress, develop a value system, and factors like genetics, physical health, developmental stage, physical fitness, family, geography, culture, and economic status
• Physical assessment involves the collection of objective data through a physical examination, which is a systematic way of collecting data using examination techniques to assess the client's current health status, functional abilities, and to establish diagnoses and care plans
• Preparation guidelines for physical examination include introducing oneself to the client, verifying identity, explaining procedures, ensuring privacy, providing adequate lighting, gathering materials, performing hand hygiene, and positioning the patient appropriately for different assessments
• Materials/equipment needed for physical examination may include a height chart, weighing scale, Snellen’s chart, penlight, sterile gloves, tongue depressors, gauze, tuning fork, stethoscope, wristwatch, tape measure, marker/pencil, record sheet, and waste receptacle
• Positioning the patient during physical examination includes standing, sitting, dorsal recumbent, supine position, Sim's position, prone position, lithotomy, and knee-chest position, each suitable for different assessments
• Assessment techniques in physical assessment involve palpation, inspection, auscultation, and percussion, with inspection being a visual examination in a methodical, deliberate, and purposeful manner
• Assessment Techniques: Palpation involves light palpation (½ inch depth for muscle tone and tenderness) and deep palpation (1 inch depth for abdominal organs and masses, avoiding pressure that can damage internal organs)
• Bimanual deep palpation is done with two hands or one hand
• Assessment Techniques: Percussion involves striking the body surface with short, sharp strokes to detect location, size, shape, and density of underlying structures, as well as to detect the presence of air and fluid in body spaces and elicit tenderness
• Percussion technique includes striking at the right angle to the pleximeter using quick, sharp but relaxed wrist motion, withdrawing the plexor immediately after the strike to avoid damping the vibration, and striking each area twice before moving to a new area
• Common sounds heard when percussing include flat (soft), dull (medium), resonance (loud), hyper-resonance (very loud), and tympany (loud)
• Assessment Techniques: Auscultation involves listening to sounds produced within the body, with characteristics of sound heard during auscultation including pitch (ranging from high to low), loudness (ranging soft to loud), quality (gurgling or swishing), and duration (short, medium, or long)
• Auscultation uses the bell of the stethoscope to detect low-pitched sounds and the diaphragm to detect high-pitched sounds, with specific instructions for using each part of the stethoscope
• Diagnostic Tests: Common diagnostic tests include blood tests (e.g., complete blood count), serum electrolytes (e.g., sodium, potassium), arterial blood gas (ABG) tests, blood chemistry (e.g., enzymes, hormones), capillary blood glucose tests, stool specimens, urine specimens (e.g., clean voided, clean-catch, timed, indwelling catheter), sputum specimens, throat cultures, and chest X-rays
• Diagnostic Testing Phases: Include pretest (client preparation and data collection), intratest (specimen collection and performing diagnostic testing), and post-test (nursing care of the client and follow-up activities and observations)
• Nursing Diagnosis appropriate for clients undergoing diagnostic testing include anxiety or fear related to possible diagnosis of acute or chronic illness, impaired physical mobility due to prescribed bed rest, and deficient knowledge regarding the diagnostic test