1. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 12 Assessing

2. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Four Types of Nursing Assessments Comprehensive initial Focused Emergency Time-lapsed

3. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessing: The Primary Source of Information Is the Patient

4. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Comprehensive Initial Assessment Performed shortly after admittance to hospital Performed to establish a complete database for problem identification and care planning Performed by the nurse to collect data on all aspects of patient’s health

5. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Focused Assessment May be performed during initial assessment or as routine ongoing data collection Performed to gather data about a specific problem already identified, or to identify new or overlooked problems Performed by the nurse to collect data about the specific problem

6. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Emergency Assessment Performed when a physiologic or psychological crisis presents Performed to identify life-threatening problems Performed by the nurse to gather data about the life- threatening problem

7. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Time-Lapsed Assessment Performed to compare a patient’s current status to baseline data obtained earlier Performed to reassess health status and make necessary revisions in plan of care Performed by the nurse to collect data about current health status of patient

8. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Establishing Assessment Priorities Health orientation Developmental stage Need for nursing

9. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Medical vs. Nursing Assessments Medical assessments –Target data pointing to pathologic conditions Nursing assessments –Focus on the patient’s response to health problems

10. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Objective Data vs. Subjective Data Objective data –Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them –e.g., elevated temperature, skin moisture, vomiting Subjective data –Information perceived only by the affected person –e.g., pain experience, feeling dizzy, feeling anxious

11. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Characteristics of Data Purposeful Complete Factual and accurate Relevant

12. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Sources of Data Patient Family and significant others Patient record Other healthcare professionals Nursing and other healthcare literature

13. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins The Skill of Nursing Observation Determines the patient’s current responses (physical and emotional) Determines the patient’s current ability to manage care Determines the immediate environment and its safety Determines the larger environment (hospital or community)

14. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Four Phases of a Nursing Interview Preparatory phase Introduction Working phase Termination

15. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Purpose of a Nursing Physical Assessment Appraisal of health status Identification of health problems Establishment of a database for nursing intervention

16. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Successful Interview Techniques Focus on the patient during the interview Listen to the patient attentively Ask about patient’s main problem first Pose questions and comments in appropriate manner Avoid comments and questions that impede communication Use silence and touch appropriately

17. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Type of Questions Used in Interviews Closed questions—elicit specific information Open-ended questions—allow the patient to verbalize freely Reflective questions—encourage patient to elaborate on thoughts and feelings Direct questions—validate or clarify information

18. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Collaborating Members of the Healthcare Team

19. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Problems Related to Data Collection Inappropriate organization of the database Omission of pertinent data Inclusion of irrelevant or duplicate data, erroneous or misinterpreted data Failure to establish rapport and partnership Recording an interpretation of data rather than observed behavior Failure to update the database

20. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins When to Verify Data When there is a discrepancy between what the person is saying and what the nurse is observing When the data lack objectivity

21. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Validating Inferences Performing a physical examination using proper equipment and procedure Using clarifying statements Sharing inferences with other team members Checking findings with research reports

22. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Documentation of Data Enter initial database into computer or record in ink on designated forms the same day patient is admitted Summarize objective and subjective data in concise, comprehensive, and easily retrievable manner Use good grammar and standard medical abbreviations Whenever possible, use patient’s own words Avoid non-specific terms subject to individual interpretation or definition

23. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Tell whether the following statement is true or false. A nursing assessment duplicates a medical assessment by focusing on the patient’s responses to the health problem. A. True B. False

24. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer Answer: B. False A nursing assessment does not duplicate a medical assessment, rather it focuses on the patient’s responses to the health problem.

25. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which one of the following assessments would be performed on a patient to gather data about his previously diagnosed liver cancer? A. Initial assessment B. Focused assessment C. Emergency assessment D. Time-lapsed assessment

26. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer Answer: B. Focused assessment Rationale: In a focused assessment the nurse gathers data about a condition that has already been diagnosed. An initial assessment is performed shortly after the patient is admitted to a healthcare agency or service. When a physiologic or psychological crisis presents, the nurse performs an emergency assessment. A time-lapsed assessment compares a patient’s current status to baseline data obtained earlier.

27. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Tell whether the following statement is true or false. Most healthcare institutions establish a minimum data set that specifies the information that must be collected from every patient and uses a structured assessment form to organize or cluster these data. A. True B. False

28. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer Answer: A. True Most healthcare institutions establish a minimum data set that specifies the information that must be collected from every patient and uses a structured assessment form to organize or cluster these data.

29. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Tell whether the following statement is true or false. A patient rates his pain as a “7” on a pain rating scale. This rating is considered to be objective data. A. True B. False

30. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer Answer: B. False A patient rates his pain as a “7” on a pain rating scale. This rating is considered to be subjective data.

31. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Question In which of the following phases of the nursing interview does the nurse gather all the information needed to form the subjective database? A. Preparatory phase B. Introduction C. Working phase D. Termination

32. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer Answer: C. Working phase Rationale: The patient database is obtained in the working phase. In the preparatory phase, the nurse prepares the patient and the environment for the interview. The introduction sets the tone for the remainder of the interview. The termination is the conclusion of the interview.