1. Assessment, Nursing Diagnosis, and Planning
Chapter 5
Assessment, Nursing Diagnosis, and Planning
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

2. Chapter 5
Lesson 5.1
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

3. Learning Objectives Theory
Identify the purpose of assessment (data collection).
Discuss the three basic methods used to gather a patient database.
Differentiate objective data from subjective data.
Identify sources of data for the formulation of a patient database.
Clinical Practice
Collect assessment data for a patient and document it.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

4. Assessment (Data Collection)
During assessment, the nurse collects patient health data
Data are gathered on specific topics, organized into a database, and documented
LPN/LVNs may be asked to collect data as part of the assessment
Although assessment is an RN function rather than an LPN/LVN function according to most state nurse practice acts, LPN/LVNs assist the RN in the gathering of data.
In what ways would the LPN/LVN be expected to help with patient assessment?
What kinds of data might the RN ask the LPN/LVN to collect?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

5. Assessment (Data Collection) (cont’d)
Approaches to assessment
Functional health patterns assessment as formulated by Mary Gordon
Focused assessment (focuses on a specific problem)
Basic needs assessment based on Maslow’s hierarchy of basic needs
In a functional assessment, the data are collected in a structured format that helps identify patient strengths and weaknesses within the context of essential human functions.
In a focused assessment, data are collected only for areas with obvious problems, deviations, or alterations, leading to quick implementation of care. This approach is useful when the patient is in acute distress.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

6. The Interview Based on gathering data—is not a social interaction
Good communication essential
Communication may be:
Verbal
Nonverbal, noting body posture, facial expressions, movement, and gestures
During the interview, it is important that patients be made to feel relaxed so that they are open and honest in relaying personal information.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

7. The Interview (cont’d)
Consists of three basic stages
The opening, during which rapport is established with the patient
The body of the interview, during which necessary questions are presented
The closing, during which information is summarized
In the opening, the patient should be notified of the purpose of gathering data as well as how the information will be safeguarded.
In the closing, the patient should be allowed to ask questions, especially about the interview process.
Why would you want to summarize the information you gathered during the closing? (to ensure that you understood key data points and that the information is correct)
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

8. Chart Review
Data collection tool; helps obtain information to interview patient or prepare for the day’s patient assignment
Chart review should include:
Face sheet and physician’s orders
Nurses’ notes (at least the past 24 hours)
Physicians’ progress notes and history and physical examination
Medication administration record
Surgery operative report and pathology report
Diagnostic tests
Nursing admission history and assessment
Fall risk assessment and skin assessment
Nursing care plan or problem list
The chart review gives a quick overview or profile of the patient.
Ideally, the chart review should be done before the first contact with a new patient. However, this is not always achievable in a busy health care setting.
What might you determine from reviewing the nurses’ notes that you wouldn’t necessarily find in physicians’ notes? (specific information about activities of daily living, mobility, elimination patterns, nutritional intake, etc.)
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

9. The Physical Examination
Use techniques of inspection, auscultation, palpation, and percussion
Carried out in a systematic manner
Head-to-toe examination
Ongoing nursing data collection and examination focuses on the body systems in which there is a problem or potential problem
The physical examination is performed by the RN. Parts of the exam may be delegated to the LPN/LVN.
A complete head-to-toe physical examination can take an experienced person 30 minutes to an hour to complete. An abbreviated examination is often done by the nurse on admission.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

10. Head-to-Toe Assessment
Initial observation
Breathing
How the patient is feeling
General appearance
Skin color
Affect
A quick overall assessment is to be followed up with a more in-depth assessment, as time permits.
Sometimes a walking shift report is made, in which each patient is quickly observed prior to exchanging information among nurses.
What are some findings of an initial observation that would be immediately reported to the RN or charge nurse? (difficulty breathing, shortness of breath, apnea, pallor, cyanosis, agitation, etc.)
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

11. Head-to-Toe Assessment (cont’d)
Level of consciousness
Awake, alert, and oriented
Ability to communicate
Language spoken, any communication deficits
Mentation status
Able to comprehend, form thoughts
Appearance of the eyes
Pupil size, light reaction
The patient can be awake without being alert; however, the patient cannot be alert without being awake.
Level of consciousness follows a continuum from fully awake to drowsy, lethargic, stuporous, and finally unarousable or comatose.
Orientation looks at the content of the responses. It indicates patient awareness of date, place, and self. If all are intact, it is indicated as “oriented X3.”
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

12. Head-to-Toe Assessment (cont’d)
Vital signs
Temperature
Pulse rate
Rhythm, strength, apical, radial
Respirations
Rate, pattern, depth; oxygen saturation
Blood pressure
Within normal limits
Compare with previous readings
Depending on the clinical setting, the LPN/LVN may be asked to obtain the vital signs. However, this may be delegated to a nursing assistant.
Vital signs that are abnormal should be reported to the RN or charge nurse because additional actions may be required.
How often should the vital signs be assessed? (As often as ordered by the physician or requested by the RN based on changing status of the patient. Vital signs are checked at least once per shift for the hospitalized patient, and perhaps once per day in less acute settings, such as rehab.)
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

13. Head-to-Toe Assessment (cont’d)
Heart and lungs
Heart sounds, normal S1-S2
Lungs
Lung sounds
Rales, wheezes, diminished breath sounds
Abdomen
Shape, hardness, bowel sounds, last bowel movement, voiding, appetite, nausea
In the acute care setting, heart, lungs, and abdomen should be auscultated at least once during a shift.
How often should the heart, lungs, and abdomen be auscultated in the home care setting? (each visit)
When would you suspect there might be a problem with inadequate bowel elimination? (if the patient reports—or the notation indicates—no bowel movement for 3 or more days)
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

14. Head-to-Toe Assessment (cont’d)
Extremities
Ability to move all extremities well
Ability to move within normal range
Skin turgor, color, temperature
Peripheral pulses
Edema
For the patient who cannot follow commands well, spontaneous movements in bed can be observed and noted in the chart. If the patient guards one side, or doesn’t move an extremity effectively, some impairment might be implied.
What might indicate that the peripheral circulation is compromised in one extremity? (diminished pulses; pale or cyanotic coloration, especially distal; decreased temperature; edema, etc.)
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

15. Head-to-Toe Assessment (cont’d)
Tubes and equipment
Oxygen cannula, chest tubes
NG tubes, PEG tubes, jejunostomy tube
Urinary catheter
Type and amount of drainage
Dressings and drainage
Pulse oximeter
Traction devices
Pain status
The location of all tubes and equipment attached to the patient should be noted.
The anatomic insertion site should be noted for all chest tubes, drainage tubes, etc.
What other types of equipment would you note if present? (IVs, wound suction devices, sequential compression devices [SCDs], CPM devices, etc.)
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

16. Assessment in Long-Term Care
Extensive initial assessment performed when patient enters long-term care facility
Reassessment at fixed intervals and as the patient’s condition changes
Physical assessment, health history, medication history, and a functional assessment performed
A functional assessment often is supplemental to the history and physical examination. A functional assessment yields information about the patient’s level of independence and ability to perform ADLs. It also helps identify problems that can be addressed by nursing.
For Medicare patients, a reassessment by an RN is necessary every 90 days, and the care plan is reviewed and revised at that time.
Why does Medicare only require a reassessment every 90 days? (Status may not change even if done more frequently and costs increase. On the other hand, 90 days is a minimal standard to help ensure that the plan of care is still effective.)
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

17. Assessment in Home Health Care
Initial patient assessment in the home is usually performed by the RN
The LPN/LVN, when doing private duty in a home, will need to perform daily assessments and maintain necessary documentation
Changes found on assessment should be reported to the RN supervisor
The family is assessed regarding attitude and ability to help with care of the patient, their ability to provide emotional support for the patient, their ability to cope with the situation, and teaching that will need to be provided for them.
How does the home health care assessment differ from the hospital assessment?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

18. Question 1
As part of an assessment, the nurse asks for information from the patient. This information is a subjective indication of illness perceived by the patient and is called a/an:
assessment.
symptom.
sign.
observation
Answer: 2
Rationale: Symptoms are subjective indications of illness that are perceived by the patient.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

19. Question 2
All of the following components can be found on the chart except the:
face sheet.
physician’s order.
patient’s history and physical.
patient’s nurse assignment.
Answer: 4
Rationale: The patient’s nurse assignment is part of the unit staffing information posted on each unit, but it is not part of the patient’s chart.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

20. Question 3
Linda knows as part of her nursing assignment that she is to review and update the nursing care plan on her patients:
hourly.
every shift.
every 24 hours.
weekly.
Answer: 3
Rationale: The nursing care plan is reviewed and updated every 24 hours. Necessary changes can be made anytime.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

21. Chapter 5
Lesson 5.2
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

22. Learning Objectives Theory
Correlate patient problems with nursing diagnoses from the accepted North American Nursing Diagnosis Association–International (NANDA-I) list.
Clinical Practice
Analyze the data collected to determine patient needs.
Identify appropriate nursing diagnoses from the NANDA list for each assigned patient.
Prioritize the nursing diagnoses.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

23. Analysis Database analyzed for cues that deviate from the norm
Pieces of data are sorted
Related data are grouped or clustered
Missing data are identified
Inferences are made regarding the patient’s problems
Once the information has been gathered, the database is analyzed for cues that indicate deviations from the norm.
What are cues?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

24. Nursing Diagnosis
A nursing diagnosis statement indicates the patient's actual health status or the risk of a problem developing, the causative or related factors, and specific defining characteristics (signs and symptoms)
The medical diagnosis (i.e., stroke or cerebrovascular accident) is never included in the construction of the nursing diagnosis.
The RN indicates the nursing diagnoses, but the LPN/LVN is expected to contribute to the plan of care once the diagnoses have been identified.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

25. Etiologic Factors Causes of the problem
Signs are abnormalities that can be verified by repeat examination and are objective data
Symptoms are data the patient has said are occurring that cannot be verified by examination; symptoms are subjective data
What is the difference between objective data and subjective data? (Subjective data are what the patient tells you; objective data are what you collect by examining the patient.)
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

26. Defining Characteristics
Characteristics (signs and symptoms) that must be present for a particular nursing diagnosis to be appropriate for that patient
Supply the evidence that the nursing diagnosis is valid
Nursing diagnoses differ from medical diagnoses in that the nursing diagnosis defines the patient's response to illness, whereas the medical diagnosis labels the illness.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

27. Prioritization of Problems
Problems ranked according to their importance
Physiologic needs for basic survival take precedence (i.e., airway and circulation)
After physiologic needs are met, safety problems take priority
Every nurse must attempt to look at each patient holistically, keeping psychosocial needs in mind while working on physical problems
Priorities of care are set so that the nurse will first attend to the most important interventions for the high-priority problems for each patient.
Order can be guided by the hierarchy of needs adapted from Maslow, by the patient's beliefs regarding the level of importance of each problem, and by what is most life-threatening or problematic for the patient.
How can the nurse help to meet psychosocial needs?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

28. Nursing Diagnosis in Long-Term Care/Home Health Care
LPN/LVN employed in a long-term care facility begins the care planning process when patient is admitted
The supervising RN determines appropriate nursing diagnoses, reviews the care plan, modifies it as needed, and finalizes it for the chart
Home health care
Nursing diagnosis must include problems identified in the family’s ability to cope with the illness or situation and teaching needs for care of the patient
Care plan encompasses patient and whole family
The same process is used to analyze data, identify problems and safety concerns, and to choose nursing diagnoses appropriate for the new resident.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

29. Question 4
Which one of the following sets of assessment data is most likely to be present with the nursing diagnosis Risk for infection?
Fever, dysuria, change in urine concentration, and urinary urgency
Abdominal pain, sore mouth, hyperactive bowel sounds, and leukopenia
Fatigue, electrocardiographic changes, dependent edema, and activity intolerance
Abdominal incision, decreased hemoglobin, and indwelling catheter present
Answer: 4 
Rationale: Assessment data used to make a nursing diagnosis include medical history, physical examination, laboratory analyses, and data from the nursing history and assessment. A "risk for" nursing diagnosis describes human responses that may develop in a vulnerable person. Options 1 and 2 contain data that indicate an actual infection, while option 3 has no data to indicate an increased risk for infection.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

30. Chapter 5
Lesson 5.3
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

31. Learning Objectives Theory
Identify appropriate outcome criteria for selected nursing diagnoses.
Plan goals for each patient and write outcome criteria for the chosen nursing diagnoses.
Clinical Practice
Write specific goal/outcome statements.
Plan appropriate nursing interventions to assist the patient in attaining the goals/expected outcomes.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

32. Planning: Goals and Expected Outcomes
Goal: what is to be achieved by nursing intervention
Short-term goals
Achievable within 7 to 10 days or before discharge
Long-term goals
Take many weeks or months to achieve
Often relate to rehabilitation
Expected outcome: statement of goal patient is to achieve as a result of nursing intervention
How are expected outcomes derived?
The patient or significant others should be included in the goal-setting process.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

33. Interventions (Nursing Orders)
Designed to alleviate problems and to achieve expected outcomes
Should include giving medications and performing ordered treatments
Individualized to the patient’s needs
Nursing interventions should give specific steps to be executed, or actions to be taken, in order for the outcome to be achieved.
How could you be more specific about an intervention, such as maintaining skin integrity? (For example, reposition patient every 2 hours, use padding to protect bony prominences, move patient in/out of bed with slide board, etc.)
Examples of nursing interventions include:
Monitoring high-risk problems
Alleviating pain or discomfort
Reducing stress
Maintaining skin integrity
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

34. Documentation
Planning not complete until plan is documented and is part of patient’s medical record
Plans constructed by LPN/LVNs must be reviewed by the RN before they are placed in the chart
The plan of care should be reviewed and updated once every 24 hours
Although the LPN/LVN may be quite knowledgeable on the patient’s status, the RN is ultimately responsible for the appropriateness of the plan of care.
Many health care facilities now use computerized programs to assist in constructing the nursing care plan.
The nurse chooses the appropriate nursing diagnoses and then is presented with computer screens from which to choose the expected outcomes and the nursing interventions.
As the patient’s status changes, the care plan is updated to reflect the current status.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

35. Question 5
A nurse has established expected outcomes for an assigned patient. The nurse carries out this important activity for the purpose of:
evaluating the occurrence of complications.
measuring quality of care.
measuring the effectiveness of nursing interventions.
stopping care when outcomes are met.
Answer: 3
Rationale: The purposes of establishing expected outcomes are to direct nursing interventions, maintain continuity of nursing care, and measure the effectiveness of nursing interventions.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.