Nursing Assessment

Nursing Process - Nursing Assessment

1. NURSING ASSESSMENT BY ASOKAN R, ASSO. PROFESSOR, KINS KIIT DEEMED TO BE UNIVERSITY

2. What Is Nursing Assessment?

3. It is a systematic, rational method of planning and providing individualized nursing care.

4. Characteristics of Nursing Assessment Cyclic and dynamic Problem solving technique Open and flexible There is no absolute beginning Client centered Interpersonal and collaborative Planned

5. Goal directed Permits creativity for the nurse and clients Emphasizes feedback Universally applicable Decision making Critical thinking skills Directed towards client response and disease

6. What you mean by Assessing?

7. Assessing Systematic and continuous collection, organization, validation and documentation of data. Carried out during all phases.

8. TYPES Types vary according to their purpose, timing, time available and client status. Medical assessment focus on disease. Nursing assessment focus on client’s response to health problem. Initial assessment Problem focused assessment Emergency assessment Time lapsed assessment

9. Assessment process Collecting data Organizing data Validating data Documenting data

10. Collecting data Process of gathering information about a client’s health status. Database – all the information about client. Nursing history Physician’s history and physical examination Results of laboratory and diagnostic tests Materials contributed by other health personal.

11. TYPES OF DATA Subjective data (symptoms or covert data) Client’s sensations, feeling, values, beliefs, attitude, perception of personal health status and life situation. Objective data ( sign or overt data) Seen, heared, felt, smelled, observed and physical examination.

12. SOURCE OF DATA Primary ( client) Secondary ( family member, other support persons, other health professionals, records and reports, laboratory & diagnostic analysis & relevant literature. client ( too ill, young, confused) support people ( unconscious, physically and emotionally abused) client records ( medical, therapies & laboratory records)

13. Health care professionals ( nurses, social workers, physicians & physiotherapist) literature ( professional journals & reference texts) standard ( compare) cultural & social health practices spiritual beliefs Additional required assessment data (WHO) Nursing interventions and evaluation criteria Information about medical diagnosis, treatment and prognosis.

14. DATA COLLECTION METHOD Observing Interviewing Examining

15. OBSERVING ( FIVE SENSES) Noticing the stimuli Selecting, organizing & interpreting data. (body temperature, activity, BP & environmental temperature) Distinguishing the stimuli should be meaningful. Experienced nurse. Example: clinical signs of distress Clients safety Immediate environment

16. INTERVIEWING Planned communication or a conversation with a purpose Two approaches Direct interview – highly structured and elicited specific information (emergency situations) Nondirective interview – rapport building interview, asking open ended questions. Combination of directive & Nondirective – information gathering interview (client express worry about surgery)

17. Kinds of interview questions Closed / open ended questions Neutral / leading questions Closed ended questions : yes / No When, where, who, what, do, is, how. Open ended questions invite the clients to freedom to talk, broad topic to be discussed, response, clients attitude & beliefs example: How do you feel? need of the nurse will choose.

18. Neutral questions Client can answer without direction or pressure from the nurse Example: Why do you think you had the operation? Leading questions Question suggests what answer is expected less opportunity to decide. Example: you are stressed about surgery tomorrow. Are not you?

19. Planning the interview (review available information) Time, place, seating arrangement. Time – freedom of pain, physically comfortable, no interruptions & unhurry. Seating arrangement – create formal setting, with no table between, create less formal atmosphere, feel equal both, circular chair arrangement can avoid. If bed – 45 degree angle, position is less formal, overbed table between the clients and nurse. Distance – neither too small nor too great, 3 to 4 feet distance

20. Stages of interviews Establishing rapport – begin with greeting ( good morning ), self introduction, accompanied nonverbal gestures, continue rapport development. Careful not to overdo this stage, too much superficial talk will make anxiety.

21. Orientation stage – explain the purpose, nature of interview (what information is needed) Body – communicate, thinks, feels, knows & open ended questions. Use communication technique. Closing – when needed information obtained, when decided not to give any more information, unable to offer more information e.x : fatigue. facilitating future interactions.

22. EXAMINING Physical exam (systematic data collection methods that uses observational skills. Use techniques of inspection, palpation, percussion & auscultation. Head to toe approach Body system examination Screening examination.

23. ORGANIZING DATA Nursing health history, Nursing assessment. The framework may be modified according to the clients physical status. Health care agencies have developed their own structured assessment tools. Gordon’s functional health pattern framework Orem’s self-care model Roy’s adaptation model.

24. VALIDATING DATA Data must be complete, factual & accurate. Validation is “double checking or verifying data to conform accurate & factual”. It helps, Information complete Ensure objective & subjective data agree Obtained additional information

25. Differentiate between cues & inferences. Cues – subjective/objective data that can be directly observed by the nurse. can see, hear, feel, smell & measure. Inferences – nurse’s conclusion / interpretation of the cues. e.x : a nurse observes the cues that an incision is red, hot & swollen. Inference that incision is infected.

26. GUIDELINES Compare subjective & objective data E.x : feeling hot – measure body temperature Clarify any ambiguous or vague statements E.x : I have felt sick on and off 6 months. Describe what your sickness is like & what you mean by on & off. Be sure your data consist cues and not inference E.x : dry skin & reduced tissue turgor. Dehydration. So collect additional information.

27. IV. Double check the data that are extremely abnormal. E.x ; resting pulse of 50 b/m or BP of 180/95 mm Hg. So use another equipment or someone else do. V. Determine the presence of factors that may interfere with accurate measurement. Eg : crying infant will have abnormal respiration rate. So need quieting before accurate assessment. VI . Use references to explain phenomena. ( textbooks, journals, research reports) Eg : tiny purple or bluish black swollen area under the tongue of an elderly patient to be abnormal until reading about physical changes of aging.

28. Not all data require validation (height, weight, date of birth & laboratory studies) Only need validation in any discrepancies between data obtained. Aware about values & beliefs Avoid premature closure.

29. DOCUMENTING DATA Recorded in a factual manner & not interpreted by the nurse. E.x : coffee 240 ml, juice 120 ml, 1 egg, 1 slice of toast rather than “appetite good” ( judgement ). Judgment or conclusion such good appetite or normal appetite may have differences. Subjective data in the clients own words.

30. thank u