chapter 12 assessing

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Copyright 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 12Assessing


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Four Types of Nursing Assessments

Comprehensive initial

Focused

Emergency

Time-lapsed


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Assessing: The Primary Source ofInformation Is the Patient


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Comprehensive Initial Assessment

Performed shortly after admittance to hospital

Performed to establish a complete database for problemidentification and care planning

Performed by the nurse to collect data on all aspects ofpatients health


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Emergency Assessment

Performed when a physiologic or psychological crisispresents

Performed to identify life-threatening problems

Performed by the nurse to gather data about the life-threatening problem


7/32Copyright 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Time-Lapsed Assessment

Performed to compare a patients current status tobaseline data obtained earlier

Performed to reassess health status and make necessaryrevisions in plan of care

Performed by the nurse to collect data about currenthealth status of patient



Establishing Assessment Priorities

Health orientation

Developmental stage

Need for nursing



Medical vs. Nursing Assessments

Medical assessments

Target data pointing to pathologic conditions

Nursing assessments

Focus on the patients response to health problems



Objective Data vs. Subjective Data

Objective data

Observable and measurable data that can be seen,heard, or felt by someone other than the personexperiencing 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



Characteristics of Data

Purposeful

Complete

Factual and accurate

Relevant



Sources of Data

Patient

Family and significant others

Patient record

Other healthcare professionals

Nursing and other healthcare literature



The Skill of Nursing Observation

Determines the patients current responses (physical andemotional)

Determines the patients current ability to manage care

Determines the immediate environment and its safety

Determines the larger environment (hospital orcommunity)



Four Phases of a Nursing Interview

Preparatory phase

Introduction

Working phase

Termination



Purpose of a Nursing Physical Assessment

Appraisal of health status

Identification of health problems

Establishment of a database for nursing intervention



Successful Interview Techniques

Focus on the patient during the interview

Listen to the patient attentively

Ask about patients main problem first

Pose questions and comments in appropriate manner

Avoid comments and questions that impede

communication

Use silence and touch appropriately



Type of Questions Used in Interviews

Closed questionselicit specific information

Open-ended questionsallow the patient to verbalizefreely

Reflective questionsencourage patient to elaborate onthoughts and feelings

Direct questionsvalidate or clarify information



Collaborating Members of the HealthcareTeam



Problems Related to Data Collection

Inappropriate organization of the database

Omission of pertinent data

Inclusion of irrelevant or duplicate data, erroneous ormisinterpreted data

Failure to establish rapport and partnership

Recording an interpretation of data rather than observedbehavior

Failure to update the database


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When to Verify Data

When there is a discrepancy between what the person issaying and what the nurse is observing

When the data lack objectivity


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Validating Inferences

Performing a physical examination using properequipment and procedure

Using clarifying statements

Sharing inferences with other team members

Checking findings with research reports


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Documentation of Data

Enter initial database into computer or record in ink ondesignated 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 patients own words

Avoid non-specific terms subject to individualinterpretation or definition


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Question

Tell whether the following statement is true or false.

A nursing assessment duplicates a medical assessmentby focusing on the patients responses to the healthproblem.

A. True

B. False


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Answer

Answer: B. False

A nursing assessment does not duplicate a medicalassessment, rather it focuses on the patients responsesto the health problem.


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Question

Which one of the following assessments would beperformed 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


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Answer

Answer: B. Focused assessment

Rationale:

In a focused assessment the nurse gathers data about acondition that has already been diagnosed.

An initial assessment is performed shortly after thepatient is admitted to a healthcare agency or service.

When a physiologic or psychological crisis presents, thenurse performs an emergency assessment.

A time-lapsed assessment compares a patients currentstatus to baseline data obtained earlier.


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Question


Most healthcare institutions establish a minimum data setthat specifies the information that must be collected fromevery patient and uses a structured assessment form toorganize or cluster these data.

A. True

B. False


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Answer

Answer: A. True

Most healthcare institutions establish a minimum data setthat specifies the information that must be collected fromevery patient and uses a structured assessment form toorganize or cluster these data.


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Question


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


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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.


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Question

In which of the following phases of the nursing interviewdoes the nurse gather all the information needed to form

the subjective database?A. Preparatory phase

B. Introduction

C. Working phase

D. Termination


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chapter 12 assessing

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