M4 LESSON 2: ASSESSMENT

• Assessment

  -         systematic, deliberate process

  -         Continuous data collection

  -         Analyzes data about the patient, client’s human response, health status, strengths and concerns

  -         Finding all “necessary puzzle pieces” to get a picture of your patient’s health status.
• Focused and Relevant (Characteristics of an assessment that promotes critical thinking)


  must be focused to gain relevant information, depending on purpose and context
• Systematic (Characteristics of an assessment that promotes critical thinking)


  helps pay attention to what's important, learn how to prioritize, be comprehensive, and avoid omission of errors
• 2 Main Types of Assessment

  • Data Base Assessment
  • Focus Assessment
• Comprehensive and Accurate (Characteristics of an assessment that promotes critical thinking)


  factual and complete
• Recorded in a Standardized Way (Characteristics of an assessment that promotes critical thinking)


  value the importance of completing a standardized tool designed to promote an assessment that’s purposeful, relevant, systematic and complete.
• Data Base Assessment

  -         “start of care” assessment

  -         Comprehensive information gathered on initial contact with the person to assess all aspects of health status
• Focus Assessment

  -         Data gathered to determine the status of a specific condition
• Assessment Activities

  1. Collecting Data

  2. Identifying Cues & Making Inferences

  3. Validating / Verifying Data

  4. Organizing / Clustering Data

  5. Identifying Patterns / Testing First Impressions

  6. Reporting and Recording Data
• Direct Assessment


  the most up to date information comes from your direct assessment of the patient
• Primary Source

  patient
• Secondary Sources


  significant others, nursing and medical records, verbal and written consultations, diagnostic or laboratory studies
• Ways of collecting data

  1. Observation of patient
  2. Interview of patient, family, and other nurses
  3. Examination of patient
  4. Medical record review
• Observation


  noting information or cues through the use of senses
• Interview


  structured form of communication that the nurses use to collect data face to face
• Direct Interview


  highly structured and elicit specific information by asking closed ended questions that call for a specific amount of data.
• Indirect Interview


  the nurse allows the client to control the purpose, subject matter and pacing
• Close Ended Questions


  restrictive and generally require only short answers giving specific information; often begin with when, where, who, what, do, does, did
• Open Ended Questions


  lead or invite clients to explore their thoughts or feelings
• Time (Planning the interview setting)


  need to be scheduled when the client is comfortable and free of pain
• Place (Planning the interview setting)


  must have adequate privacy to promote communication
• Distance (Planning the interview setting)



  most people feel comfortable 3 to 4 ft. during an interview
• Opening (Stages of an Interview)


  sets the tone of the remainder of the interview
• Establish Rapport


  process of creating good will and trust
• Orientation


  explaining the purpose and nature of the interview
• Body (Stages of an Interview)


  client communicates what he feels, think, knows and perceives in response to questions from the nurse
• Closing (Stages of an Interview)


  important in facilitating future interactions
• Examination of Patient has to be:

  Thorough

  Systematic

  Skilled
• Approaches in Examination of Patient:


  Head to toe Assessment

  Body System Approach
• Skills used in Physical Exam:

  Inspection

  Palpation

  Percussion

  Auscultation
• Medical Records Review


  to relate past health care history of the patient to present; to identify what medication the patient is taking so that the assessment can include the effectiveness of the medication
• Subjective Data


  information given verbally by the patient
• Objective Data


  observed data of the nurse
• Cues


  the subjective and objective data identified
• Inference


  how one interprets or perceive a cue
• Verifying Data


  helps to avoid assumptions, missing key information
• Organizing Data


  to identify nursing diagnoses; set priorities; identify signs and symptoms; helps think critically
• Maslow's Hierarchy of Needs


  -         Used to set priorities

  -         Physiologic - vital signs, nutrition, sex, pain

  -         Safety and security- energy level, presence factors

  -         Love and belongingness- Family and relationship

  -         Self esteem - honors, awards, recognitions

  -         Self actualization - self fulfilment, selfless service
• ABC (AIRWAY BREATHING CIRCULATION)


  -         Used to set priorities

  -         I.E. Bleeding- circulation, Difficulty of risk Breathing Airway and Breathing
• BODY SYSTEM


  -         Used to identify signs and symptoms of possible medical problems

  -         I.E. Body systems- cardiovascular, respiratory, lymphatic systems