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Chapter 16

Nursing Assessment

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Five-Step Nursing Process

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Nursing Process

The nursing process is a variation of scientific

reasoning.

Practicing the five steps of the nursing process allows

you to be organized and to conduct your practice in a

systematic way.

You learn to make inferences about the meaning of a

patients response to a health problem or generalize

about the patients functional state of health.

Through assessment, a pattern begins to form.

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Critical Thinking Approach

to Assessment

Assessment involves collecting information

from the patient and from secondary sources

(e.g., family members), along with interpreting

and validating the information to form acomplete database.

Two stages of assessment: Collection and verification of data

Analysis of data

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Case Study

Ms. Carla Thompkins is being admitted to the

medical-surgical unit as a postop patient. Ms.

Thompkins, a 52-year-old schoolteacher, is

recovering from a below-the-knee amputation (BKA)

secondary to complications of type 2 diabetes.

Ms. Thompkins is admitted to the unit not only so her

recovery from the BKA may be monitored, but also

because Ms. Thompkins is going to receive

preliminary occupational and physical therapy to helpher adapt to the amputation.

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Database

The purpose of assessment is to establish a

database about the patients perceived

needs, health problems, and responses to

these problems. In addition, the data reveal related goals,

experiences, health practices, values, and

expectations about the health care system.

Critical thinking skills help you to synthesizerelevant information and use it in a purposeful

way.

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Data Collection

Sources of data Patient (interview, observation, physical

examination)the best source of information

Family and significant others (obtain patientsagreement first)

Health care team

Medical records

Scientific literature

Nurses experience

Subjective vs. objective data

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Cues and Inferences

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Comprehensive Assessment

Approaches

Use of a structured database format, based

on an accepted theoretical framework or

practice standard

Example: Gordons model of functional healthpatterns

Problem-oriented approach

Assessment moves from general to specific.

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Process of Assessment

Collect data.

Cluster cues, make inferences, and identify

patterns and problem areas.

Critically anticipate. Be sure to have supporting cues before

making an inference.

Knowing how to probe and frame questions is

a skill that grows with experience.

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Methods of Data Collection

Patient-centered interview = An organized

conversation with the patient Set the stage (preparation, environment, greeting).

Set an agenda/gather information about patientsconcerns.

Collect the assessment or nursing health history;

assure the patient of confidentiality.

Terminate the interview (cue the end).

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Interview

Orientation phase

Working phase

Termination phase

*Communication techniques, environment

and cultural competence important factors

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Interview Techniques

Open-ended vs. closed-ended questions

Back-channeling

Probing

------------------------------------------- Because a patients report includes subjective

information, validate data from the interview

later with objective data.

Obtain information (as appropriate) about apatients physical, developmental, emotional,

intellectual, social, and spiritual dimensions.

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Cultural Considerations

To conduct an accurate and complete

assessment, you need to consider a patients

cultural background.

When cultural differences exist between youand a patient, respect the unfamiliar and be

sensitive to a patients uniqueness.

If you are unsure about what a patient is

saying, ask for clarification to prevent makingthe wrong diagnostic conclusion.

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Nursing Health History

Biographical

information

Patient expectations

Reason for seeking

health care

Present illness or

health concerns

Health history Family history

Environmental history Psychosocial history

Spiritual health Review of systems

Documentation of findings

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Nursing Health History

Biographical information Present illness or health concerns Family history Psychosocial history Review of Systems Client experiences *health history(social, emotional, physical ,

developmental, intellectual and spiritual)

Environmental history Spiritual health Documentation of findings

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Physical Examination

Observation of behavior

Diagnostic and laboratory data

Interpreting and assessment of date

Making nursing judgements (critical thinking)

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Data Documentation

The last component of a complete

assessment

Legal and professional

responsibility

Requires accurate and approvedterminology and abbreviations

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Case Study (contd)

During the assessment, Ms. Thompkins

complains of pain at the incision site. Ms. Thompkins report of pain is an example of

what type of data?

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Quick Quiz!

1. A patient is admitted to the hospital with

shortness of breath. As the nurse assesses this

patient, the nurse is using the process of

A. Evaluation.B. Data collection.

C. Problem identification.

D. Testing a hypothesis.

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Next Assessment Steps

Physical examination = An investigation of

the body to determine its state of health

Observation of patient behavior (verbal vs.

nonverbal) Diagnostic and laboratory data

Interpreting and validating assessment data.

Validation of assessment data consists of

comparison of data with another source todetermine accuracy of the data.

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Case Study (contd)

Which of the following statements or questions made

by Yolanda to Ms. Thompkins addresses the nature

of Ms. Thompkins pain?

(Select all that apply.)

A. Describe your pain to me.

B. Is the pain worse in the morning or in the

evening?

C. Place your hand over the area that is

uncomfortable.D. Rate your pain on a scale of 0 to 10.

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Quick Quiz!

2. The nursing process organizes your

approach to delivering nursing care. To

provide care to your patients, you will need to

incorporate nursing process andA. Decision making.

B. Problem solving.

C. Interview process.

D. Intellectual standards.

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Case Study (contd)

True or False: Yolanda knows that the best

source of information regarding Ms.

Thompkins care is the surgeon.