chap. 12 assessing

the process of collecting, organizing, validating, and recording data (information) about a client's health status

significant information that is helpful in making decisions

Information

all the pertinent patient information that enables a comprehensive and effective plan of care to be designed and implemented

rapid focused assessment conducted to determine potentially fatal situations

assessment conducted to assess a specific problem; focuses on pertinent history and body regions

the judgement reached about a cue

comprehensive nursing assessment resulting in baseline data that enables the nurse to make a judgment about a patient's health status, ability to manage his or her own healthcare, and need for nursing and to plan individualized, holistic healthcare for the patient

face to face data collection

a standard established by healthcare institutions that specifies the information that must be collected from every patient

assessment of the patient by interview to identify the patient's health status, strengths, health problems, health risks, and need for nursing care

information (data) that is detectable by an observer or can be tested against an accepted standard; can be seen, heard, felt, or smelled

Involves using one or more of the five senses to gather information

systematic examination of the patient for objective data to better define the patient's condition and to help the nurse in planning care; usually performed in a head-to-toe format

Systematic method for collecting data from all body systems

Data relating to a client's health problem that are given in the client's own words.

an assessment that is scheduled to compare a patient's current status to baseline data obtained earlier

act of confirming or verifying

Focused Initial Time-lapsed Emergency

is performed shortly after the patient is admitted to the healthcare agency or service. the purpose is to establish a complete database for problem identification and care planning

conducted to assess a specific problem. Ex: abdominal pain, nurse asks about bladder and bowel habits. what when did symptoms start , what makes it worst?

Time Period: During any physiologic or psychologic crisis of the client; Purpose: To identify life-threatening problems. To identify new or overlooked problems; Example: Rapid assessment of a person's airway, breathing status, and circulation during a cardiac arrest. Assessment of suicidal tendencies or potential for violence.

an assessment that is scheduled to compare a patient's current status to baseline data obtained earlier homecare with visiting nurses.

when nurses make a assessment they do not duplicate medical assessments . Medical assessments target the pathological conditions, whereas Nursing assessments focus on the patients responses to health problems , the unique focus of nursing assessment is on the patients responses to actual or potential health problems.

objective data is collected by the person doing the interview using sense what you see , smell , hear,feel. subjective data - is given in the patients own words what they tell you

1. Patient 2. Family and significant others 3.Patient records 4.Other healthcare professionals 5.Nursing and other healthcare literature

the purpose for which the assessment is being performed offers the best guideline about what type and how much data to collect . Assessment priorities are based on the patients health orientation,developmental stage , culture, and need for nursing- patient health problems dicate assessment priority

The nursing history should clearly identify the patients strengths and weaknesses; health risk, such as hereditary and environmental factors; and potential and existing health problems. The nursing history focuses on getting to know the person. Patient interview: -preparatory phase: the nurse should insure the environment that the interview is being conducted is private and relaxed. -introductory phase: starts off "good afternoon Ms. Smith my name is Skippy and I'm going to be your nursing student for today." -working phase: during this phase nurse gathers information to form the subjective data base. the accuracy and completeness is important -termination: the successful interview is concluded carefully. Highlight the keys points making sure the patient agrees with you. Always ask " is there anything else you would like us to know that will help us plan your care?"

the examination of the patient is for objective data. it identifies pathological conditions and their causes, the nursing physical assessment focuses on the patient's functional abilities, if a deficit is present like a CVA a nurse will check for a patients reasoning and sensor motor ability. Nurse uses their senses.

dynamic

Let's talk about this we often get new information that we can incorporate successfully into the plan of care. Sometimes the steps of the process interact or overlap.

"In addition to providing us with valuable information about your health status it will allow us to plan and deliver individualized holistic nursing care that draws on your strengths.

Perform and document a focused assessment on skin integrity.

You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care.

Subjective Data

Introduce yourself and ask the patient if he would like the wife to stay.

Explain to the patient and her son that you will obtain the services of a hospital approved translator.

Validate your findings

You made an inference that she is fine because she made no complaints, how do you validate this?

Appropriate communication involves correct timming and proper documentation.

NURSE SHOULD TRY AND USE THE PATIENTS OWN WORDS OF HOW THEY FEEL YOU SHOULD USE " " MARKS or para phrased : avoid using adaquate,good average,normal,poor,small, large

Nurse Ruth reassesses the B/P at 140/80 this is Not considered evaluating --Collection of pt data is considered assessment regardless of when it occurs.