assessing
the systematic and continuous collection, organization, validation, and documentation of data
Establishing a Database
obtain a nursing health history
conduct a physical assessment
review client records
review nursing literature
consult support persons
consult health professionals
Components of a Nursing Health History
biographic data
chief complaint
history of present illness
past history
family history of illness
lifestyle
social data
psychological data
patterns of health care
directive interview
highly structured and elicits specific information
nondirective interview
rapport building interview
Type of Interview Question - restrictive, generally yes/no or short answers
closed questions
Planning the Interview
time
place
seating arrangement
language
Stages of an Interview
1. Opening -
establish rapport, orientation
2. Body - ask questions
3. Closing - terminates interview when needed information has been obtained
Interview Closing Techniques
1. offer to answer questions
2. conclude with a "well" statement ["Well, those are all the questions I have now"]
3. thank the client
4. express concern for the client's welfare and future
5. plan for the next meeting
6. provide a
summary to verify accuracy and agreement
cephalocaudal
head to toe approach
screening examination [review of systems]
brief review of essential functioning of various body parts or systems
Organizing Data
* conceptual models/frameworks [Gordon,
Orem, Roy]
* wellness models - habits, behaviors, values, attitudes
* non-nursing models
Wellness Models Generally Include...
healthy history
physical fitness evaluation
nutritional assessment
life-stress analysis
lifestyle and health habits
health beliefs
sexual health
spiritual health
relationships
health risk appraisal
Maslow's Hierarchy of Needs [priority]
physiological needs [survival needs]
safety & security
love & belonging
self-esteem
self-actualization
Developmental Theories
* Havighurst's age periods and developmental tasks
* Freud's five stages of development
* Erikson's eight stages of development
* Piaget's phases of cognitive development
* Kohlberg's stages
of moral development
Validating Assessment Data
*ensure the assessment information is complete
* ensure that objective and related subjective data agree
* obtain additional information that may have been overlooked
* clarify any ambiguous or vague statements
* be sure the data consists of cues and not inferences
* double check extremely abnormal data
* avoid jumping to conclusions and focusing
in the wrong direction to identify problems
* determine the presence of factors that may interfere with accurate measurement
* use references to explain phenomena
cues
subjective of objective data that can be directly observed [see, hear, smell, feel, measure]
inferences
the nurse's interpretation or conclusions made based on cues
Type of Interview Question - open-ended questions
invite clients to discover and explore, elaborate, clarify, or illustrate their thoughts and feelings
Specific information
questions tends to be elicited by closed questions: ex: "When did the pain start?"
Leading questions
questions direct the client's answers.
Neutral questions
questions invite the client to explore feelings.
Open-ended questions
questions allow the client to elaborate on responses.
body
The part of the interview that is focused on gathering data from the client is the
The opening
the part of the interview when the nurse establishes rapport with the client.
Collection of all necessary information for a thorough appraisal
Use of a conceptual or theoretical framework for collecting and organizing assessment data ensures?
Assessing
is the systematic and continuous collection, organization, validation, and documentation of data.
Cephalocaudal
or head to toe approach begins the examination at the head; progressed to the neck, thorax, abdomen, and extremities, and ends at the toes.
Closed questions
used in the directive interview, are restrictive and generally require "yes" or "no" or short factual answers giving specific information. Closed questions often begin with "when", "where", "who", "what","do""or
Cues
are subjective or objective data that can be directly observed by the nurse; that is what the client says or what the nurse can see, hear ,feel smell, or measure.
Data
information
Database
contains all the information about a client; it includes the nursing health history, physical assessment, primary care providers history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.
Directive interview
is highly structured and elicits specific information. Nurse establishes the purpose of the interview and controls the interview, at least at the outset. The client responds to questions but may have limited opportunity to ask questions or discuss concerns.
Inferences
are the nurses interpretation or conclusions made based on the cues [e.g. a nurse observes the cues that an incision is red, hot , and swollen; the nurse makes the inference that the incision is infected]
Interview
is a planned communication or a conversation with a purpose, for example, to get or give information, identify problems or mutual concern, evaluate change, teach provide support, or provide counseling or therapy.
Leading question
by contrast, I usually closed, used in a directive interview, and thus directs the clients answer. " your stressed about surgery tomorrow, aren't you"?
Neutral question
is a question the client can answer without direction or pressure from the nurse, is open ended, and is used in nondirective interviews.
Nondirective interview
or rapport- building interview, the nurse allows the client to control the purpose, subject matter, and pacing.
Objective data
also referred to signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled, and they obtained by observation or physical examination.
Open ended questions
associated with the nondirective interview, invite clients to discover and explore, elaborate, clarify, or illustrate their thoughts of feelings. An open end question specifies only the broad topic to be discussed, and invites answers longer than one or two words, "how have you been feeling lately"?
Review of systems
brief review of essential functioning of various body parts or systems.
Rapport
is an understanding between two or more people.
Screening examination
also called review of systems; is a brief review of essential function of various body parts or systems. An example is the nursing admission assessment form- data obtained from this examination are measured against norms or stands, such as ideal height and weight standards or norms for body temperature of blood pressure levels.
Signs
objective data or overt data.
Symptoms
also referred as subjective data, or covert data, are apparent only to the person affected and can be described or verified only by that person. Includes the clients sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situation.
Validation
is the act of "double checking" or verifying data to confirm that is accurate and factual. Validating data helps the nurse complete the task : ensure the assessment information is complete; ensure that objective and related subjective data agree. Obtain additional information that may have been overlooked. Differentiate between cues and inferences. Avoid jumping to conclusions and focusing in the wrong direction to identify problems.
Identify Major characteristics of the nursing process
Cyclic and dynamic rather than static
Client Centered
Problem-solving and systems theory
Decision Making
Interpersonal and collaborative
Universal applicability
Critical
thinking skills
Identify the purpose of assessing
to focus on the clients responses to a health problem
Identify the four major activities associated with the assessing phase
Data collection: What information does the nurse need to know.
Data Validation: Is the client data normal or abnormal? Is the info collected
accurate?
Data Organization: What data are related?
Pattern Identification: Under which patter should the data be grouped?
What is subjective data?
subjective data is about symptoms or corporate data. It is only apparent to the person affected and can only be described by the person affected. It includes sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situations.
Identify three methods of data collection and give examples of how each is useful
Observing- gathering data using the senses
Interviewing- planned communication or a conversation with a purpose
Examining-physical examination
Compared directive and non directive approaches to interviewing
directive-nurse
establishes the purpose and control of the interview.
Used to gather and give information when time is limited, in an emergency. For example,
non-directive-it builds rapport, client controls the purpose, subject, matter, and pacing. Combination of directive and nondirective approach is usually appropriate during the information gathering interview
What are Closed ended questions?
it is a close question, which is restrictive and limits to you yes or no or factual comments. Requires less effort and information from the clients. Some questions are; what medications do you take? Or are you having pain now?
Describe important aspects of the interview setting
time, place, seating arrangement, distance, language.
Contrast various frameworks used for nursing assessment.
Gordon provides a framework of 11 functional health patterns. Patterns is used to signify sequence of recurrent behavior. The nurse collects data about dysfunctional as well as functional behavior and is able to organize data and discern emerging patterns.
Roy classifies observable behavior to four categories: physiological, self-concept, role function, and interdependence.
Orem's self-care model uses a universal healthcare requisite
Wellness models are used to assist clients to identify health risks and to explore lifestyle habits and health behaviors, beliefs, values, and attitudes that influence levels of wellness.
What are four types of assessments?
Initial Nursing Assessment
Problem focused
Emergency
Time-Lapsed
What is an initial nursing assessment?
Perfromed
within a specified time period
Establisehs complete database
Problem focused
Ongoing process integrated with care
Determines status of a specific problem
Emergency Assessment:
Performed during physiologic or psychologic crises.
Time-Lapsed
Occurs
several month after initial
Compares current status to baseline
What types of data is obtained through observation collection?
Skin Color- vision
Body or breath odors- smell
Lung or heart sounds- sound
Skin temperature- touch
What types of data is collected through the interviewing collection?
get Or give
information.
Identify problems of mutual concern.
Evaluate change.
Teach
provide support.
Provide counseling or therapy
What is objective data?
they are signs or overt data. Detectable by an observer, can be measured or tested against an accepted standard. Can be seen, heard, felt, or smelled. Obtain through observation or physical examination.
What are two sources of data?
primary source-the client.
Secondary source-all other sources of data, should be validated if possible
What are open ended questions?
they specify broad topics to discuss.
Invite longer answers.
Get more information from the client.
Useful to change topics and illicit attitudes
What types of data is collected through the examination collection process?
systematic data collection method.
Uses observation and action, auscultation,palpation, and percussion.
Vital signs, height, and weight.
cephalocaudal approach.
Screening examination
what is Gordon's help perception, health management pattern?
it describes the clients perceived pattern of health and well-being and how health is managed. Examples is aware and/or understands medical diagnosis, gives thorough history of illnesses and surgeries, compliance with medication regimen, relates progression of illness in detail
what is Gordon's nutritional metabolic pattern?
it describes the client pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrients supply. Example height and weight, eating pattern, temperature, skin turgor, nausea.fluid and electrolyte balance, hair and nails
what is Gordon elimination pattern?
describes the patterns of excretory function, bowel, bladder, and skin. Examples last bowel movement was and it was.... Decreased urinary frequency.
what is Gordon's activity exercise pattern?
it describes the pattern of exercise, activity, leisure, recreation. Examples: musculoskeletal impairment, difficulty sleeping, because of the cough, respiratory issues, daily exercising, mobility and immobility, range of motion, blood pressure, pulse.
what is Gordon's cognitive, perceptual pattern?
it describes sensory perceptual and cognitive patterns.it includes vision, hearing, taste, touch and smell pain perception and management, language, memory, and decision-making ability. Orientation to time, place and person.
what is Gordon's self perception and self-concept pattern?
it describes their attitude about the self, self-concept, comfort, body image, feeling state.
what is Gordon's role relationship pattern?
it describes the clients pattern of roll participation relationships. Or the effectiveness of relationships with family, friends, business associates
what is Gordon sexuality reproductive pattern?
describes the client patterns of satisfaction and dissatisfaction with sexuality pattern; describes reproductive patterns. Can be actual or perceived problems
what is Gordon's coping stress tolerance pattern?
it describes the client general open pattern in effect business of the pattern in terms of stress tolerance.
what is Gordon's value belief pattern?
it describes the patterns of values, beliefs, including spiritual, and goals that guide the clients choices or decisions. It pretty much describes the own value systems.
what are non-nursing models?
the body systems model.
Maslow's hierarchy of needs.
Developmental theories
validating assessment data
`compare subjective and objective data to verify the client statements with your observations.
`Clarify any ambiguous or vague statements.
`Be sure your data consists of cues and not inferences such
as dry skin and reduced tissue turgor versus dehydration
`double check data that are extremely abnormal.
`Determine the presence of factors that may interfere with accurate measurement, such as a crying infant will have an abnormal respiratory rate.
`Use references to explain phenomena.
`Avoid jumping to conclusions.
`Make sure the assessment is complete
how to document
record client
data
record factual manner not interpreting by nurse.
Record subjective data with quotes and client's own words
Which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process?
Identifying major problems or needs.
Organizing data in the client's family history.
Establishing short-term and long-term goals.
Administering an antibiotic.
Identifying
major problems or needs.
Rationale: Identifying problems/needs is part of a nursing diagnosis. For example, a client with difficulty breathing would have Impaired Gas Exchange related to constricted airways as manifested by shortness of breath [dyspnea] as a nursing diagnosis. Organizing the family history is part of the assessment phase. Establishing goals is a part of the planning phase. Administering an antibiotic is part of the implementation phase.
Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care?
Proposes hypotheses.
Generates desired outcomes.
Reviews results of laboratory tests.
Documents care.
Reviews results of laboratory tests.
Rationale: During assessment, data are collected, organized, validated, and documented. Hypotheses are generated during diagnosing; outcomes
are set during planning; and documentation occurs throughout the nursing process.
Which of the following elements is best categorized as secondary subjective data?
The nurse measures a weight loss of 10 pounds since the last clinic visit.
Spouse states the client has lost all appetite.
The nurse palpates edema in lower extremities.
Client states severe pain when walking up stairs.
Spouse
states the client has lost all appetite.
Rationale: Primary data come from the client [option 4], whereas secondary data come from any other source [chart, family]. Subjective data are covert [reported or an opinion], whereas objective data can be measured or validated [weight—option 1, edema—option 3]. If the spouse had stated that the client had eaten only toast and tea, this would be secondary objective [measured] data.
The nurse wishes to determine the client's feelings about a recent diagnosis. Which interview question is most likely to elicit this information?
"What did the doctor tell you about your diagnosis?"
"Are you worried about how the diagnosis will affect you in the future?"
"Tell me about your reactions to the diagnosis."
"How is your family responding to the diagnosis?"
"Tell me about your reactions to the diagnosis."
Rationale: Eliciting feelings requires
an open-ended question that does more than seek factual information [option 1] and cannot be answered with a single word [option 2]. The family can provide indirect information about the client, but is not most likely to provide the most accurate information [option 4].
The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following?
Correlation of the data with other members of the
health care team.
Demonstration of cost-effective care.
Utilization of creativity and intuition in creating a plan of care.
Collection of all necessary information for a thorough appraisal.
Collection of all necessary information for a thorough appraisal.
Rationale: Frameworks help the nurse be systematic in data collection. Other members of the health care team may use very different conceptual organizing frameworks so data may not
correlate [option 1]. Cost-effective care [option 2] is more likely to occur with systematic application of the Nursing Process, but use of a framework for assessment alone may not accomplish this goal. Because the framework is structured and because of the nature of client needs/problems, creativity and intuition in care planning are not assured [option 3].
Which of the following is the purpose of assessing?
Establish a database of client
responses to their health status.
Identify client strengths and problems.
Develop an individualized plan of care.
Implement care, prevent illness, and promote wellness.
Establish a database of client responses to their health status.
Rationale: Assessing provides a database of the client's physiological and psychosocial responses to his or her health status. Client strengths and problems [option 2] are identified in the diagnosing phase of
the nursing process, a care plan is established [option 3] in the planning phase, and care, prevention, and wellness promotion [option 4] are part of the implementing phase.
In the validating activity of the assessing phase of the nursing process, the nurse performs which of the following?
Collects subjective data.
Applies a framework to the collected data.
Confirms data is complete and accurate.
Records data in the client record.
Confirms data is complete and accurate.
Rationale: In validating, the nurse confirms that data is complete and accurate. Subjective data is collected in the collecting activity [option 1], a framework is applied to the data in the organizing activity [option 2], and data is recorded in the documenting activity [option 4].
A major characteristic of the nursing process is which of the following?
A focus on
client needs.
Its static nature.
An emphasis on physiology and illness.
Its exclusive use by and with nurses.
A focus on client needs.
Rationale: The nursing process focuses on client needs. It is dynamic rather than static [option 2], emphasizes client responses rather than physiology and illness [option 3], and is collaborative rather than used exclusively by nurses [option 4].
Which of the following would be true regarding use of the observing method of data collection?
When observing, the nurse uses only the visual sense.
Observing is done only when no other nursing interventions are being performed at the same time.
Data should be gathered as it occurs, rather than in any particular order.
Observed data should be interpreted in relation to other sources of collected data.
Observed data should be interpreted in relation to
other sources of collected data.
Rationale: Interpreting collected data is necessary to help validate its accuracy. Observing includes the senses of smell, hearing, and touch in addition to vision [option 1]. Using priority setting, observing must often be performed simultaneously with other activities [option 2]. A systematic approach to observing data helps ensure nothing is missed and the nurse pays attention to the most important data first [option 4].
Which of the following represent effective planning of the interview setting? Select all that apply.
Keep the lighting dimmed so as not to stress the client's eyes.
Ensure that no one can overhear the interview conversation.
Stand near the client's head while they are in the bed or chair.
Keep approximately 3 feet from the client during the interview.
Use a standard form to be sure all relevant data are covered in the interview.
Ensure that no one can overhear the interview conversation.
Keep approximately 3 feet from the client during the interview.
Use a standard form to be sure all relevant data are covered in the interview.
Rationale: The nurse plans the interview so that privacy is observed. A comfortable distance between nurse and client to respect the client's personal space is about 3 feet. Using a standard form will help ensure the nurse doesn't omit gathering any vital information.
Lighting should be at a normal level—neither bright nor dim [option 1]. The nurse should be at the same height as the client, usually sitting, at approximately a 45-degree angle facing the client. The nurse standing over the client creates an uncomfortable atmosphere for an interview [option 3].
When the client states that "my head hurts and my vision is blurry," what type and source of data is this?
Primary and objective
Primary and
subjective
Secondary and objective
Secondary and subjective
Primary and subjective
Objective: Identify the four major activities associated with the assessment process.
Rationale: The source is primary [the client] and the data are subjective [symptoms]. In Answer 1, the source is primary, but the data are not objective. In Answer 3, the source is primary [the client] and the data are not objective. In answer 4, the source is primary [the client] and the data are subjective.
Which of the following data should the nurse validate?
The client's temperature is 101.2.
The chart says the client is allergic to penicillin.
The client says, "I feel like my blood sugar is high."
The client's pulse is 104.
The client says, "I feel like my blood sugar is high."
Objective: Differentiate objective and subjective data and primary and
secondary data.
Rationale: The nurse should make an attempt to validate subjective data [symptoms] from the client. Answer 3 is subjective data that the nurse should validate by checking the client's blood sugar. The client's temperature of 101.2 is objective data. The chart's saying the client is allergic to penicillin is objective data. The client's pulse of 104 is objective data.
What kind of assessment is being performed when the nurse
asks the client, "Why did you come to the clinic today?"
Initial assessment
Emergency assessment
Problem-focused assessment
Time-lapsed reassessment
Initial assessment
Objective: Contrast various frameworks used for nursing assessment.
Rationale: The nurse performs various types of assessments depending on the nature of the situation. In this case, it is gathering information for an initial database. The emergency assessment does not indicate the client came to the clinic for an emergency, life-threatening condition. The problem-focused assessment does not indicate the client has an established problem. The time-lapsed reassessment does not indicate the client has previous baseline data.
Which of the following is an example of objective data?
The physician says the client is experiencing chest pain.
The client complains of nausea.
The client's abdomen is round
and soft.
The client's spouse asks that he be returned to bed because he is tired.
The client's abdomen is round and soft.
Objective: Differentiate objective and subjective data and primary and secondary data.
Rationale: Objective data are those that are detectable by an observer or can be measured or tested against an accepted standard. Information that is reported to the nurse by someone else is subjective. The client's complaining of nausea is subjective data, a symptom that is reported by the client. That the client's spouse asked that he be returned to bed because he is tired is subjective data, reported to the nurse by another person.
The nurse asks a client, "What happened to your leg?" This is an example of:
A neutral question
A leading question
A closed question
An open-ended question
An open-ended question
Objective:
Compare directive and nondirective approaches to interviewing.
Rationale: Nurses use various types of questions in interviews. When a nurse wants a client to give a more complete answer and to elaborate, an open-ended question is frequently used. A neutral question is one that is non-directive, and allows the client to explore feelings. A leading question is directive, and gives the client less opportunity to decide if the answer is true. A closed question invites only a yes, no, or short, factual answer.
Which of the following positions assumed by the nurse and the client facilitates an easy exchange of information?
The client is in bed and the nurse stands at the foot of the bed
Seated; the nurse places the chairs at right angles to one another, about a foot apart
The client is in bed and the nurse stands at the side of the bed
The client is in bed and the nurse sits on a chair at a 45-degree angle to the
bed
The client is in bed and the nurse sits on a chair at a 45-degree angle to the bed
Objective: Describe important aspects of the interview setting.
Rationale: The nurse strives for a less formal atmosphere, where the nurse and client can feel on more equal terms. In Answer 1, the nurse may intimidate the client, who feels the nurse has greater status. Answer 2 is less formal; the nurse and client are too close together for the client to feel comfortable. The client may feel that his personal space is being invaded. When the client is in bed and the nurse stands at the side of the bed, the nurse is in a position where the client may feel intimidated because the nurse is not at eye level.
Which of the following questions is likely to elicit specific information?
"When did the pain start?"
"You are looking forward to that therapy to relieve the pain, aren't you?"
"How have
you dealt with pain in the past?"
"How do you feel about beginning therapy to treat the pain?"
"When did the pain start?"
Objective: Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each.
Rationale: Specific information tends to be elicited by closed questions. Leading questions direct the client's answers. Neutral questions invite the client to explore feelings. Open-ended questions allow the client to elaborate on responses.
Which of the following is an example of a leading question?
"How do you feel about the test results?"
"What do you know about your upcoming surgery?"
"How long has your knee been bothering you?"
"You are excited about going home, aren't you?"
"You are excited about going home, aren't you?"
Objective: Compare directive and nondirective approaches to
interviewing.
Rationale: A leading question is used in a directive interview and directs the client's answer.
Answer 1 is an open-ended question that can be answered without direction or pressure from the nurse.
Answer 2 is an open-ended question that requires the client to elaborate.
Answer 3 is a closed question that requires a factual answer.
During which stage of the interview should the nurse ask, "How long have you had this
symptom?"
Opening
Body
Closing
Examination
Body
Objective: Describe important aspects of the interview setting.
Rationale: The part of the interview that is focused on gathering data from the client is the body. The nurse uses open and closed questions. The opening is the part of the interview when the nurse establishes rapport with the client. The closing is the conclusion of the interview. The examination is the gathering of objective data.
List the four major activities associated with the assessment process.
The four assessing components include: collect data, organize data, validate data, and document data.
Objective: Identify the four major activities associated with the assessment process.
Rationale: The four assessing components include: collect data, organize data, validate data, and document data.