Nursing Process: Nursing Assessment

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Nursing Process: Nursing Assessment

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1. Nursing Process: Nursing Assessment George Ann Daniels, MS, RN

2. Assessment “Continuous and systematic collection, validation, and communication of client data .”(Harrington, 1996)

3. Assessment Purpose: Collect, validate and organize data about a client’s state of wellness, functional ability, physical status, strengths, and responses to actual and potential health problems. Initial, focused, time-lapsed and emergency assessment are done depending on the circumstances

4. Essential pre-assessment activities Choose a framework for assessment and documentation Gordon’s functional health patterns Control the environment Work on assessment skills Observation Interviewing Physical exam Intuitions

5. Types of Data Subjective: facts presented by the client that show his/her perception Objective: facts that are observable and measurable by the nurse, involves use of the senses Seeing Hearing Smelling Touching

6. Cues A word used to describe the individual pieces of data or “hints” about what is going on with the client Also called assessment findings Cues are analyzed to arrive at appropriate NDX

7. Sources of Data Primary: from the client, considered the most reliable if the client is deemed a good historian Nursing judgment Secondary: significant others, the medical or health record, lab tests, diagnostic procedures, meds, past medical HX, other health team members, and literature review Data needs to be validated

8. Organization of Data Need to use an organized assessment framework to help cluster assessment data (cues)into meaningful groups RSU uses Gordon’s Functional Health Patterns

9. Health Perception-Health Management Client’s awareness of personal health and well-being; health practices; understanding of how health practices contribute to health status To assess this pattern, focus on a general survey of the client’s health status and their usual health behaviors EG: BSE, Immunization Hept B, annual physicals, flu shots Client’s perceived level of health and own personal practices, prevention practices Describe personal health concerns ID risk factors How does client stay healthy Hospital expectationsEG: BSE, Immunization Hept B, annual physicals, flu shots Client’s perceived level of health and own personal practices, prevention practices Describe personal health concerns ID risk factors How does client stay healthy Hospital expectations

10. Nutritional-Metabolic Pattern Patterns of food and fluid intake, relationship of intake to metabolic needs; skin assessment, fluid volume, thermoregulation To assess this pattern, focus on eating habits, appraisal of appetite, weight loss or gain, changes in skin, hair,or nails. 24 hour dietary recall/food diary Impact of psychologic factors on nutrition How has the present condition interfered with eating and appetite Food allergies Client’s Knowledge of nutrition24 hour dietary recall/food diary Impact of psychologic factors on nutrition How has the present condition interfered with eating and appetite Food allergies Client’s Knowledge of nutrition

11. Elimination Pattern Patterns of excretory function (Bowel, Bladder,and Skin), and client perception of same Assess usual bowel and bladder elimination habits,laxative use, excretory function of skin (e.g. excessive perspiration) Frequency, amount, color, aroma, character Urinary/bowel devices: catheter, ostomiesFrequency, amount, color, aroma, character Urinary/bowel devices: catheter, ostomies

12. Activity -Exercise Patterns of exercise, activity, leisure recreations, and ADL; factors that interfere with desired or expected individual pattern Assess mobility status, exercise routine, leisure activities, cardiovascular status Ability to perform Note limitationsAbility to perform Note limitations

13. Sleep- Rest pattern Patterns of sleep and rest-relaxation periods during 24 hour day. As well as quality and quantity Assess regular sleep habits and routine Individual perception of the effectiveness of sleep and relaxation “Do you feel rested when you wake up?” Clients activities RT bedtime and usual sleep patternIndividual perception of the effectiveness of sleep and relaxation “Do you feel rested when you wake up?” Clients activities RT bedtime and usual sleep pattern

14. Cognitive-Perceptual Pattern Adequacy of sensory modes, such as vision, hearing taste, touch, smell, pain perception, cognitive functional activities Assess changes in cognitive function, ability to hear, see, and speak, presence of pain, numbness, or other sensations Communication, memoryCommunication, memory

15. Self-perception- Self-concept Pattern Individuals attitudes about self, perception of abilities, body image, identity, general sense of worth and emotional patterns Assess descriptions of self, physical appearance, effects of illness, major life accomplishments and changes Avoid making value judgments when assessing this patternAvoid making value judgments when assessing this pattern

16. Role- Relationship Pattern Client's perception of major roles and responsibilities in current life situation Assess client's perceptions of key relationships, observation of interactions with others Describes family, social, and work relationships. Major responsibilities Effects of present condition on role-relationshipsDescribes family, social, and work relationships. Major responsibilities Effects of present condition on role-relationships

17. Sexuality-Reproductive Pattern Client's perceived satisfaction or dissatisfaction with sexuality. Reproductive stage and pattern Assess client’s appraisal of his or her sexual role and sexual health. Interview should be appropriate to gender, age, and developmental stage Knowledge levelInterview should be appropriate to gender, age, and developmental stage Knowledge level

18. Coping-Stress Tolerance Pattern General coping pattern, stress tolerance and management, support systems, and perceived ability to control and manage situations Assess current stress level, coping ability, ability to endure life stressors, physiologic responses to stress Major loss or change in life Ways the client handles stress Stress or stressors confronting clientMajor loss or change in life Ways the client handles stress Stress or stressors confronting client

19. Value- Belief Pattern Values, goals, or beliefs that guide choices or decisions. Assess identification of valued people and possessions, source of support, religious practices Ethnic background and effects of culture and cultural belief on health practices Ethnic background and effects of culture and cultural belief on health practices

20. Measurement Criteria for ANA Standard I: Assessment: The nurse collects client health data Data collection involves client, significant others, and healthcare providers when appropriate The priority of data collection activities is determined by the client’s immediate condition or needs

21. Pertinent data are collected using appropriate assessment techniques and instruments Relevant data are documented in a retrievable form The data collection process is systematic and ongoing BREAKBREAK

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