Prelims-Coverage-for-NCM-101-Lecture.pptx

health assessment

1. Nursing Role in Health Assessment 1

2. What are the roles of nurses?

3. Roles of the Professional Nurse Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.

4. Four Main Goals of Nursing Promote Health Prevent Illness Treat human responses to health or illness Advocate for individuals, families, communities , and populations

5. Nursing and Health Promotion Health behaviors are influenced by one’s beliefs, cultures , and perception Health beliefs and experiences determine who is likely to practice healthy behaviors and why.

6. WELLNESS and ILLNESS Wellness is an integrated method of functioning oriented toward maximizing the potential of the individual. Illnesses are separate short or long events that may challenge a person’s desire for health. Health is more than merely the absence of illness.

7. Health Assessment gathering information about the health status of the patient, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings, and evaluating patient care outcome includes both a health history and physical assessment.

8. NURSING PROCESS a systematic problem-solving approach Serves as a framework Focuses on solving problems and enhancing strengths Applicable to patients in all stages of the lifespan and in all settings. Central to all nursing care Encompasses all steps taken by the nurse in caring for a patient

9. Characteristics of the Nursing Process Within the legal scope of nursing Based on knowledge-requiring critical thinking Planned-organized and systematic Client-centered Goal-directed Prioritized Dynamic

10. Benefits of the Nursing Process Provides an orderly & systematic method for planning & providing care Enhances nursing efficiency by standardizing nursing practice Facilitates documentation of care Provides unity of language for the nursing profession Is economical Stresses the independent function of nurses Increases care quality through the use of deliberate actions

11. Responsibilities as a Nurse? Recognize health problems. Anticipate complications. Initiate actions to ensure appropriate and timely treatment. Begin to think CRITICALLY!

12. Nursing Assessment The first phase of the nursing process, called assessment, is the collection of data for nursing purposes. Information is collected using the skills of observation, interviewing, physical examination, and intuition and from many sources, including clients, their family members or significant others, health records, and other health team members.

13. Assessment using the nurse's five senses critical thinking skills good clinical judgment as to what seems to be the priority problem taken thru observation, interview, physical examination

14. Nursing Diagnosis The second step in the nursing process involves further analysis (breaking the whole down into parts that can be examined) and synthesis (putting data together in a new way) of the data that have been collected.

15. Nursing Diagnosis Sort, cluster, and analyze information Identify potential problems and strengths Write a statement of problem or strength Example of a nursing diagnosis: Risk of infection related to compromised nutrition

16. Purposes of N ursing D iagnosis: Nursing diagnosis is unique in that it focuses on a client’s response to a health problem, rather than on the problem itself, and it provides the structure through which nursing care can be delivered. Nursing diagnosis also provides a means for effective communication.

17. According to the North American Nursing Diagnosis Association (NANDA) a nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for the selection of nursing interventions to achieve outcomes for which the nurse is accountable.

18. NANDA International (NANDA-I) earlier known as the North American Nursing Diagnosis Association (NANDA) is the principal organization for defining, distributing, and integration of standardized nursing diagnoses worldwide.

19. Components of a Nursing Diagnosis A nursing diagnosis has typically three components: (1) the problem and its definition, (2) the etiology, and (3) the defining characteristics.

20. Physical nursing diagnoses include those that pertain to physical processes, such as circulation (ineffective renal Tissue Perfusion), ventilation (impaired Gas Exchange), and elimination (Constipation). Psychosocial nursing diagnoses include those that pertain to the mind (acute Confusion), emotions (Fear), or lifestyle and relationships (ineffective Role Performance). Types of Diagnosis

21. Differentiating Nursing Diagnosis vs Medical Diagnosis Nursing Diagnosis Medical Diagnosis focus on unhealthy responses to health and illness. identify diseases describe problems treated by nurses within the scope of independent nursing practice. describe problems for which the physician directs the primary treatment . may change from day to day as the patient’s responses change remains the same for as long as the disease is present

22. Planning The process of prioritizing nursing diagnoses and collaborative problems, identifying measurable goals or outcomes, selecting appropriate interventions, and documenting the plan of care. The nurse consults with the client while developing and revising the plan.

23. Setting Priorities Determine problems that require immediate action Maslow’s Hierarchy of Human Needs

24. Functional Health Patterns Health Perception – Health Management Pattern describes the client’s perceived pattern of health and well-being and how health is managed. 2. Nutritional – Metabolic Pattern describes the pattern of food and fluid consumption relative to metabolic needs and pattern indicators of local nutrient supply.

25. 3. Elimination Pattern describes the pattern of excretory function (bowel, bladder) 4. Activity – Exercise Pattern describes the pattern of exercise, activity, leisure, and recreation. 5. Cognitive–Perceptual Pattern describes the sensory, perceptual, and cognitive pattern

26. 6. Sleep – Rest Pattern describes patterns of sleep, rest, and relaxation. 7. Self-perception – Self-concept Pattern describes self-concept and perceptions of self (body comfort, image, feeling state) 8. Role – Relationship Pattern describes a pattern of role engagements and relationships.

27. 9. Sexuality – Reproductive Pattern describes client’s pattern of satisfaction and dissatisfaction with sexuality pattern, describes reproductive patterns. 10. Coping – Stress Tolerance Pattern describes general coping patterns and the effectiveness of the pattern in terms of stress tolerance. 11. Value – Belief Pattern describes the pattern of values and beliefs, including spiritual and /or goals that guide choices or decisions.

28. GOAL: A general statement of purpose. end towards which all efforts are directed. OBJECTIVES: more specific statements. step-by-step family responses toward the attainment of the goal

29. Nursing Interventions Road maps directing the best ways to provide nursing care. Evidence-based nursing. Monitor health status. Minimize risks. Resolve or control a problem. Assist with ADLs. Promote optimum health and independence. must be based on the perceived diagnosis and objectives must be RATIONAL enough; realistic

30. Types of Interventions: Direct interventions : - actions performed through interaction with clients. Indirect interventions : - actions performed away from the client, on behalf of a client or group of clients. Independent Dependent Collaborative/interdependent

31. Evaluation Determining outcome achievement (met or unmet) Identifying the variables affecting outcome achievement Deciding whether to continue, modify or terminate the plan – must be in the present or past tense – nursing interventions can be modified at this stage.

32. Determining Outcome Achievement Must be aware of outcomes set for the client. Must be sure the patient is ready for evaluation. Is the patient able to meet outcome criteria? Is it: Completely met? Partially met? Not met at all? Record in progress in notes. Update care plan.

33. Documenting the Plan of Care To ensure continuity of care, the plan must be written and shared with all healthcare personnel caring for the client. Consists of: Prioritized nursing diagnostic statements. Outcomes. Interventions.

34. Documentation Clear and concise Appropriate terminology Physical assessment - Usually by Review of Systems Overview of symptoms Diet Each body system

35. Documentation Use patient’s own words in subjective data – enclose in “ ___” (quotation marks) Avoid generalizations – be specific

36. Types of Nursing Assessment Initial Comprehensive assessment On-going assessment Focused or problem-oriented assessment Emergency assessment

37. 1. Initial Comprehensive Assessment involves the collection of subjective data about the client’s perception of her health of all body parts or systems, past health history, family history, and lifestyle and health practices as well as objective data gathered during a step-by-step physical examination. The nurse typically collects subjective data, especially those related to the client’s overall function.

38. 2. Ongoing or Partial Assessment consists of data collection that occurs after the comprehensive database is established. a mini-overview of the client’s body systems and holistic health patterns as a follow-up on his health Problems that were initially detected in the are reassessed Usually performed whenever the nurse or another health care professional has an encounter with the client.

39. 3. Focused or Problem-Oriented Assessment it does not take the place of the comprehensive health assessment. Performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. Consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem.

40. 4. Emergency Assessment A very rapid assessment performed in life-threatening situations. E xample : the evaluation of the client’s airway, breathing, and circulation (known as the ABCs) when cardiac arrest is suspected. The major and only concern during this type of assessment is to determine the status of the client’s life-sustaining physical functions.

41. - To establish baseline information on the client - To determine the client’s normal function - To determine the client’s risk for dysfunction - To determine the client’s strengths - To provide data for the diagnosis phase Reasons for doing assessment:

42. Communication a process of sharing information and meaning, of sending and receiving messages.

43. Essential Parts of Communication Sender Message Receiver Feedback

44. Importance of Good Communication Enhances good rapport. Builds a trusting relationship with the patient and client. Aids in obtaining accurate data necessary for formulating a good plan of care. Helps ensure that the message you want to send is the one your patient actually receives.

45. Types of Communication Verbal Non - verbal

46. NON - VERBAL COMMUNICATION

47. Nonverbal Communication includes: Appearance Demeanor Facial Expression Attitude Silence Listening

48. 1. Appearance Ensure that your appearance is professional. Wear comfortable clothes. Make yourself presentable . Keep yourself clean.

49. 2. Demeanor Demeanor should also be professional. Display poise. Make yourself known. Don't be snobbish but don't be overly friendly or touchy.

50. 3. Facial Expression Often shows what you are truly thinking. Keep a close check on your facial expression. Keep your expression neutral and friendly.

51. 4. Attitude One of the most important nonverbal skills - nonjudgmental attitude. Keep in mind that ALL clients should be accepted, regardless of beliefs, ethnicity, lifestyle, and health care practices. Do not act superior to the client or appear shocked, disgusted, or surprised at what you are told.

52. 5. Silence Periods of silence allow you and the client to reflect and organize thoughts, which facilitates more accurate reporting and data collection.

53. 6. Listening Most important skill Becoming an effective listener takes concentration and practice. How? - Maintain good eye contact - Smile or display an open, appropriate facial expression - Maintain an open body position (open arms and hands and lean forward). Avoid preconceived ideas or biases; keep an open mind.

54. VERBAL COMMUNICATION

55. Verbal Communication Techniques: 1. Open-ended questions 2. Close-ended questions 3. Laundry list 4. Rephrasing 5. Well-placed phrases 6. Inferring information 7. Providing Information

56. 1. Open-ended questions elicit the client’s feelings and perceptions. Begin with the words “how” or “what.” Requires more than a one-word response from the client. Thus, helps reveal significant data about the client’s health status. Example: “How have you been feeling lately?”

57. 2. Closed-ended questions obtain facts focusing on specific information. typically begin with the words “when” or “did.” Clarifies information disclosed in response to open-ended questions. Example: In response to the open-ended question “How have you been feeling lately?” the client says, “Well, I’ve been feeling really sick in my stomach and I don’t feel like eating because of it.” You may be able to follow up and learn more about the client’s symptoms with a closed-ended question such as “When did the nausea start?”

58. 3. Laundry List Providing the client with a choice of words to choose from in describing symptoms, conditions, or feelings. Helps you obtain specific answers and reduces the likelihood of the client’s perceiving or providing an expected answer. Example: “Is the pain severe, dull, sharp, mild, cutting, or piercing?” “Does the pain occur once every year, day, month, or hour?” * Repeat choices as necessary.

59. 4. Rephrasing Helps you to clarify information the client has stated; it also enables you and the client to reflect on what was said. Example: Mr. G., tells you that he has been really tired and nauseated for 2 months and that he is scared because he fears that he has some horrible disease. You might rephrase the information by saying, “You are thinking that you have a serious illness?”

60. 5. Well-placed phrases Encourages client verbalization. If the client is in the middle of explaining a symptom or feeling and believes that you are not paying attention, you may fail to get all the necessary information. Listen closely to the client during his or her description and use phrases such as “um-hum,” “yes,” or “I agree” to encourage the client to continue.

61. 6. Inferring information Inferring information from what the client tells you and what you observe in the client’s behavior may elicit more data or verify existing data. Example: Your client, Mrs. J., tells you that she has bad pain. You ask where the pain is, and she says, “My stomach.” You notice the client has a hand on the right side of her lower abdomen and seems to favor her entire right side. You say, “It seems you have more difficulty with the right side of your stomach” (use the word “stomach” because that is the term the client used to describe the abdomen).

62. 7. Providing Information Another important thing to consider. Make sure you answer every question as well as you can. If you do not know the answer, explain that you will find out for the client. The more clients know about their own health, the more likely they are to become equal participants in caring for their health.

63. Therapeutic vs. Non-therapeutic Communication

64. Therapeutic Communication a process in which the healthcare professional consciously uses specific techniques to help patients better understand their condition or situation. At the same time, they also encourage patients to freely express their ideas and feelings in a relationship of mutual respect and acceptance

65. Non-Therapeutic Communication An interaction that hinders good nurse-patient relationship

66. Phases of Interview Pre - introductory phase Introductory phase Working phase Summary / Closing phase

67. Phases of Interview Pre-introductory phase - reviewing the medical record Introductory phase - introduction of self, explain the purpose, discuss types of questions, explain the need of taking notes, ensure confidentiality Working phase - eliciting client's comments on biographic data, past health history, etc. Summary / Closing phase - summarizing and validating data; identifying and discussing a plan of care; asking patient about any concern

68. Communication During the Interview Verbal - its goal is to elicit as much information about the client's health status as possible. Non-verbal - your appearance, demeanor, posture, facial expressions , and attitude.

69. COMPONENTS OF A NURSING HEALTH HISTORY Biographic data Reason for seeking health care/ chief complaint. History of present Illness Past health history Family history Review of systems Lifestyle Socio-cultural History Psychological History Occupational and environmental History

70. Biographic data Personal data including name, address, age and date of birth, gender, religion, race / ethnic origin, bed number, ward, medical diagnosis, surgery (if performed), occupation, education , and type of health plan/insurance.

71. Reason for seeking health care / chief complaint. It should be written in the client’s statement. In case of multiple problems, ask the client to indicate the priority of the complaint. Avoid using medical terminology. Write problems in chronological order.

72. History of Present Illness Expansion of Chief of Complaints Chronological order Location, quality, quantity, chronology, setting, exaggerating and relieving factors, associated symptoms, effect on sleep, and daily activities.

73. Past Health History Allergies Medical diseases such as Hypertension, Diabetes, TB, Anemia, Seizures, Arthritis, Heart Disease, Glaucoma etc. Trauma, Injury: Fracture, abdominal trauma, burns, blunt/penetrating injury, altered consciousness level. Hospitalization Childhood disease and immunization Obstetric History Drug history

74. FAMILY HISTORY- Family Health History The family history should include causes and age of death of parents, details about the health of siblings and children, and information about heart diseases, hypertension, diabetes, asthma, allergies & ethnic origin.

75. Review of Systems (ROS) A brief account from the client of any recent signs or symptoms associated with any of the body systems.

76. Respiratory History Presenting Problem / Complaint: Cough, Sputum, Hemoptysis, Wheeze, Chest Pain, Shortness of breath, Systematic symptoms, Drug History: Allergies, inhalers, nebulizer, home oxygen Social History: Smoking history measured in pack-years Contact with animals/pets Presence of stairs in or leading into flat/house Hobbies. Family History: e.g. asthma/hay fever

77. Cardiovascular History 4 main cardiovascular symptoms: Chest pain, Shortness of breath, Presence , and extent of edema, Palpitations Main risk factors for Ischemic Heart Disease: Smoking, Hypertension, Diabetes mellitus, Hyperlipidemia, Family history Past Medical History: e.g. angina, myocardial infarction, bypass operation, rheumatic fever, stroke Social History: Smoking, alcohol, etc. Family History Drug History: Allergies

78. LOCOMOTOR HISTORY Evolution of condition - Acute or chronic, Associated events and Response to treatment Current symptoms - Pain, Stiffness, Swelling , P attern of joint involvement Involvement of other symptoms – Skin, lung, eye , or kidney symptoms, malaise, weight loss, fevers , or night sweats Impact of lifestyle - Patient’s needs/ aspirations, Ability to adapt to functional loss Pain History: PQRST Use of medication for pain relief

79. Personal Data / Life Style Habit Diet Elimination pattern Sleep and rest pattern Activity and exercise pattern

80. Obstetric History Menstrual Pattern – regular/irregular History of pregnancy, labor, puerperium , and complications if any

81. Socio-Cultural History Home environment Family situation Client’s role in the family

82. Psychosocial History Psychosocial history refers to an assessment of dimensions such as self-concept and self-esteem as well as usual sources of stress and the client’s ability to cope. Sources of support for clients in crisis, such as family, significant others, religion, or support groups, should be explored

83. Occupational and Environmental History It includes collecting data regarding the client’s occupation, lifestyle in the job, working environment , etc. Collecting information includes designation, location of work, exposure to hazardous material, residing near mines, farms, factories , or shipyards, c ongestion, and overcrowding, which may spread communicable diseases.