AssessmentN314 - Assessment Assessment NURS 314 The first...

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Unformatted text preview: Assessment Assessment NURS 314 The first step in the Nursing Process: Assessment Process: Assessment is: Assessment Data/cue collection, validation, & analysis Data/cues include . . . Data/cues Any information involving client’s health status & the factors that enhance or compromise that status compromise Relevant whether “positive” or “negative” Assessment is the essential first step to NP first Without accurate and complete data, rest of nursing process has potential to be headed in the wrong direction or ineffective ineffective Where do we get our data from? from? Physical Assessment & History Client Statements & actions Medication Administration Record (MAR) (MAR) HCP Reports HCP Family Statements Family Lab/Xray Reports Lab/Xray Type of Assessment Depends on Situation: on Admission Assessment & History Focused Assessment Routine (Time-lapsed) Assessment Emergency Assessment Nursing assessment points Nursing Focus on areas of complaint/concern May gather physio and psychosocial data May simultaneously simultaneously Consider developmental/functioning level of Consider client and family client Avoid repetition of questioning Avoid unless checking BASIC mental status OR confirming critical information from shift to confirming shift (such as ___________) shift Find ways to validate “suspected” data What absolutes should always be What assessed regardless of situation? assessed Data/Cues are divided into 2 significant categories: significant Subjective Objective Objective Ideally, you want to Ideally, have some of each and apply both to your plan of care your Objective Data Objective The “signs” of “signs and symptoms”! Considered FACT It is observable or measurable by HCPs Often can be duplicated by other HCPs Examples of Objective Cues Examples Assessments/Observations: Assessments/Observations: *report as concisely & precisely as possible *report *for observed behavior, describe, DON’T interpret CNA reports refusal to eat Vomiting x 2 this shift Vomiting Distended Abdomen Prn Tylenol for fever given 3 x this shift Clenched jaw, tearful, occasional moaning NOT: looks anxious NOT: Client acted crazy *avoid judgment statements Client threw objects at staff Objective Cue Examples, cont. VS, intake & output, lab results, pain VS, scores, etc.: scores, *give the #s or ranges-NOT generalities like “high HR” or “low Potassium”, etc. like 1300 cc intake over 24 hrs. Hemoglobin 12.5 HR 80, RR 14, BP 120/80 HR HR 98-116 Potassium 2.8 Pain “4/10” Subjective Data: Subjective The “symptoms” of “signs and symptoms”! Client or family opinion, perception, Client experience, emotion experience, Can not be perceived by another (WE are not Can having their experience) having Note as “Patient reports . . .” when it is info we Note can not otherwise prove (i.e. patient reports taking all medications daily for past month) taking The data can complement each other . . . SUBJ: SUBJ: “my head hurts” my “iit is throbbing” t “I smoke daily” smoke OBJ: ---- blood pressure 190/98 ---- clenched jaw, tearful, Pain “3/10” ---- smell of smoke on clothes Or contradict each other! Or OBJ: Hemoglobin A1C of 10.2 With . . . SUBJ: “I have been following my diet SUBJ: every day for the past two months” every Why don’t the cues tell the same Why story?????? story?????? What other information do we seek? What Validation Needed! Validation Particularly w/ subjective data . . . If Particularly possible to confirm or further explore evidence, do so. evidence, Want to work w/ the most accurate Want available cues and have the full story. available Why wording matters . . . Why Your wording in documentation & reporting Your Recorded as part of client’s chart Affects perception of client for others Affects Normal? Abnormal? All worth thinking about when first gathering data . . . about Both “normal” and “abnormal” are Both significant in assessing overall situation significant Later, we will figure out what is key for the Later, moment moment Communication of assessment findings Pertinent data must be communicated in a timely Pertinent way way nurses have to make judgment of which data to report nurses to whom & when to sometimes directed by policy Types of things that may need urgent reporting: Types Significant/trending changes in vital signs Change in assessment Panic or trending lab results Client statements and actions that impact care Client direction ...
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