Chapter 1 - Evidenced-Based Assessment

Question 1

Evidenced-Based Assessment Using the Nursing Process

Answer 1

• The Nursing Process is an interactive and dynamic method for viewing and providing patient care.
• The steps of the process are cyclical, moving in a forward and backward direction.
• Assessment, Evaluation and Re-assessment occur during all steps in the process.

Nursing Process 6 phases:

1. Assessment
2. Diagnosis
3. Planning Outcomes
4. Planning Interventions
5. Implementation
6. Evaluation

Question 2

Assessment

Answer 2

Collection of data about the individual’s health state

• Purpose - to make a judgement or diagnosis
• It is systematic
• It includes gathering data that is both subjective and objective
  
  • Data may be gathered from any of the following:
    
    • Review of clinical record
    • Health history
    • Physical examination
    • Functional assessment
    • Risk assessment
    • Review of the literature

Question 3

Subjective vs. Objective data

Answer 3

• Subjected
  
  • Data communicated by the individual, family, or community
  • Obtained through interview
  • Data is what the client tells you
  • use quotation marks
  • Ex. Symptoms, values, perceptions, feelings, beliefs, sensations, attitudes
• Objective
  
  • Data gathered via observation (inspection), testing (percussion, palpation, auscultation)
  • Physical exam: what you observe through your senses
  • Assessment techniques: inspection, percussion, palpation, and auscultation
  • Through good communication, open-ended questions, no confrontation, repeating, etc.
  • Establish TRUST

Question 4

Primary vs. Secondary data

Answer 4

• Primary
  
  • Data gathered via observation (inspection), testing (percussion, palpation, auscultation)
• Secondary
  
  • Data from medical record, test results, other caregivers

Question 5

Diagnostic Reasoning

Answer 5

Process of analyzing health data and drawing conclusions to identify diagnosis

Question 6

What is a Nursing Health Assessment?

Answer 6

• Foundation of your nursing skills
• First phase of the nursing process
• Focuses on the whole person
• Assessment includes: physical, growth /development, emotional, activities of daily living (ADL’s), patterns of coping, health goals, environment, cultural / religious statuses
• Collects data for nursing and medical purposes.
• Focuses on identifying possible, actual, and/or potential health problems.
• Gathers, validates, & organizes data about the client (individual, family and community).

Question 7

Focus on Assessment

Answer 7

This course focuses on assessment, not diagnosis

• Assessment: Collection of data
• Interpretation of data is the beginning of obtaining a Nursing Diagnosis
• Identify clusters of “clues”, make inferences about clusters of “clues” validating the inferences, documentation of nursing diagnosis
  
  • Ex. Clustering data- the patient complains of pain- pain intensity scale, assess for rapid heart rate, increased BP, facial grimacing, body movement and positioning

Question 8

Priority settings

Answer 8

As you gather clinical clues during an assessment think about priority settings

1. First-level priority problems: emergent, life threatening
2. Second-level priority: Next in urgency - require prompt intervention before continued deterioration
3. Third-level priority: important to patient’s health but can wait

Question 9

Evidenced-based practice

Answer 9

• More than the use of best-practice techniques
• Encompasses the integration of research evidence, clinical expertise, clinical knowledge, and patient values and preferences

Question 10

Collecting Four types of Nursing Assessment

Answer 10

Every examiner needs to establish 4 different types of databases

• Complete Health Assessment:
  
  • Full health history and physical exam
  • Non-emergent data collected at initial visit, or on hospital admission.
• Episodic/ Problem-centered / Focused
  
  • For limited or short-term problem
  • Determination of a specific problem, targeted
  • Use OPQRSTU. Pain Assessment
• Interval, or Follow-up:
  
  • Status of an identified problem evaluated
  • Follow up on both short- and long-term issues
  • Comparison of baseline to now
• Emergency:
  
  • Urgent assessment is collection of crucial information while performing lifesaving measures
  • Focuses on ABCs
  • More rapid collection of data.

Question 11

OPQRSTU. Pain Assessment

Answer 11

• Onset- When did it begin? How long does it last (duration)?, how often does it occur (time)?
• Provoking or palliative factors? What brings it on? What makes it better? What makes it worse?
• Quality- what does it feel like? Can you describe it (throbbing, stabbing, dull)
• Region and Radiation- Does your pain radiate? Where does it spread? Point to where it hurts the most, Where does your pain go from there?
• Severity- What is the intensity? Pain scale (0-10)
• Time & Treatment- When did the symptoms first begin? What medications are you currently taking for this? How effective are the medications?
• Understanding & Impact- What do you believe is causing this? Is it affecting your ADL’s?

Do you have any other concerns?

Question 12

Organize Subjective & Objective Data

Answer 12

• Head to Toe Model or Cephalo-caudal:
  
  • Organize the assessment by proceeding with the exam in a “head to toe” order
• Body Systems Model:
  
  • Assessment is organized by body system
  • Examples: GI system, GU system
• Abbreviated—may be part or all of a 10-minute health assessment

Question 13

Cultural Considerations

Answer 13

• Be careful not to stereotype
• Consider cultural differences in your assessment technique
• Consider your own VALUES in your assessment technique
• Be aware of the perception that your beliefs, values, accepted behaviors are superior to those of other cultures

Question 14

Apply Critical Thinking to
Physical Assessment:

Answer 14

Critical thinking goes beyond just knowing the pathophysiology rather than putting together important assessment cues to determine the likely cause of a clinical problem while developing possible interventions.

• Step 1: Identify Abnormal Data from Normal Data
• Step 2: Cluster Collected Subjective & Objective data.
• Step 3: Draw Conclusions to make clinical decisions
• Step 4: Propose possible nursing diagnosis
  
  • Wellness Diagnosis
  • Risk Diagnosis:
  • Actual Nursing Diagnosis:
• Step 5: Check for defining characteristics
  
  • Must be present in order to use a nursing diagnosis
• Step 6: Confirm or rule in or rule out
  “possible” differential diagnoses
• Step 7: Document conclusions

Question 15

Possible nursing diagnosis

Answer 15

• Wellness Diagnosis
  
  • Based on identified patient strengths; indicates an opportunity for enhancement of health state & client wish to improve health
  • “Readiness for enhanced family coping”
• Risk Diagnosis:
  
  • No problem identified, but high risk for developing one. This is a 2 part statement:
    “At risk for sleep deprivation related to incisional pain”
  • Attempting to prevent the occurrence of a problem
• Actual Nursing Diagnosis:
  
  • Actual problem or dysfunctional state. This is a 3 part statement in one sentence:
    
    1. Chronic pain…
    2. R/T (related to) inflammation secondary to arthritis…
    3. as exhibited by grimacing with motion

Question 16

Health History

Answer 16

The health history is the first step of the nursing process.

• The health history:
  * Assesses all areas of the client’s life which impact physical & psychological health
  * Identifies potential/at risk as well as actual problems
  *Identifies the client’s strengths & weaknesses

Question 17

Considerations when obtaining a Health History:

Answer 17

Must DO:

• Reserve your final opinion until ALL data has been collected
• Use proven rationales to support opinions & decisions
• Continue to build your knowledge base & clinical experience
• Distinguish between fact, opinion, cues, inferences
• Ask client to clarify information when needed
• Validate information & inferences with experts
• Avoid biases and preconceived notions

Must be AWARE:

• Aware of interactions with others
• Aware of entire environment
• Aware of the fact you may not always be correct

Question 18

Components of the Health History: Biographical Data

Answer 18

• Name: initials or first name of client
• Address & phone #
• Birth date & age
• Birthplace
• Gender
• Race and/or ethnicity
• Religion/Spirituality
• Marital status (or partnered)
• Occupation: current &/or past

Consider how each component of the biographical data impacts client health.

* What risks factors might be associated with age, gender, ethnicity?
* What health risks might be associated with address, occupation?

Question 19

Health History: Source

Answer 19

Source & Reliability:

• Always note:
  
  • who gave you the information
  • how reliable that person appears to be (Is the person a good historian?)

Examples:

• “Patient appears to be a reliable historian.”
• “Patient information inconsistent.”
• “Professional/ family/ friend/ translator – pt. does not speak English.”
• “Professional/ family/ friend - patient has a diagnosis of dementia.” Note the consistency of history given.

Question 20

Reason For Visit

Answer 20

Reason for Seeking Health Care:

• Subjective statement in quotes:
  
  • “I have had a cold for 5 days.”
  • “I am here for a follow-up on my blood pressure”

What brings you in to the office today?

• Allows the nurse to assess what the patient identifies as the priority issue

Question 21

History of Present Illness (HPI)

Answer 21

A chronological history of the client’s chief complaint (reason for seeking care).

• Document this either from first appearance of symptoms to the current date or from current date backwards.
  
  • The former is the preferred method.
  • Document as fully as possible, but note that you will not be able to fully “OPQRSTU” every complaint.

Question 22

Use OPQRSTU for ALL abnormal comments or findings

Answer 22

• O=Onset
• P=Palliative/Provocative
  
  • Alleviating or aggravating factors associated with the symptoms
• Q = Quality of symptoms
  
  • burning, stabbing, etc.
  • Any other associated symptoms
• R = Radiation/ Region:
  
  • Location of problem
  • Radiate or appear anywhere else?
• S = Severity of discomfort associated with sx.
  
  • RATED on a scale
• T = Timing
  
  • When did this start
  • Gradual or sudden onset
  • Symptoms continuous or intermittent
  • How often does it occur
  • Setting it occurs in
• U = Understanding.

Question 23

OPQRSTU Examples

Answer 23

“I have chest pain”

O- “It started 2 hours ago”
P - “Walking makes it worse, I feel better when I rest”
Q - “It feels like an elephant sitting on my chest; I also have nausea”
R - “The pain runs down my left arm”
S- “It is a 12 on a scale of 1 - 10”
T - “It started at work & has been getting steadily worse”
U - “I’m afraid I am having a heart attack”

Question 24

Past Medical History (PMH)

Answer 24

• General health: “excellent”, “fair”, “poor”
  
  • Ask patient how they would rate their health
• Allergies: medication, food, environment
  
  • note what happens when exposed to allergen
• Immunizations:
  
  • be specific “all the usual” not helpful
• Major illnesses and any sequelae
• Childhood Illnesses Hospitalizations: where, why, blood transfusions, etc
• Surgeries: Previous, problems with recovery or rehab
• Current Medications
  
  • If possible, have the client bring medications to the interview.
    
    • Alternative: list of all medications currently taking
    • Include Over The Counter (OTC) and herbal

Question 25

Health History: The Genogram

Answer 25

Family health history at a glance; Useful for identifying health & stress risk factors in the client. * Usually, 3 generations are included: * The client’s parents * The client with spouse/partner, & siblings * The client’s children * If no children and/or if a significant finding is noted on history, include client’s grandparents Family Past Medical History - An accurate family history highlights diseases and conditions for which the patient may be at increased risk for

Question 26

Drawing the Genogram

Answer 26

The Genogram includes: * At least 3 generations identified as male (square) or female (circle) * Client identified with an “x” through their square or circle * Age & state of health of all persons noted * Deceased person’s squares/circles: filled in; date of death and terminal diagnosis noted * Relationships between all persons diagrammed * Key to Genogram always included in diagram

Question 27

Genogram - sample

Answer 27

* Circle members of current household. * Marital separation and divorce give date. * Miscarriage or abortion use triangle and give year. * Try to go 2 generations above the patient include parents and grandparents. Why do you need to know this information? You want to know family history of HBP, heart disease, stroke, diabetes, blood disorders, cancer, sickle cell, obesity, asthma, seizure disorder, mental illness, kidney disease, and tb. This data may have genetic significance for the patient.

Question 28

Genogram narrative example

Answer 28

* Maternal grandmother died, age 86, stroke, maternal grandfather alive and well, age 90 * Paternal grandmother, 72, diabetes with heart attack at age 65.Paternal grandfather, 76, alive & well * Dad alive and well, age 54. * Mom, 50, had ovarian cancer 3 years ago * Twin sisters, 26, alive and well * 1 brother, 24, with arthritis from sports injury * Pt. age 30, admitted with appendicitis. Divorced from husband last year. 2 year old boy and 3 y.o. girl at home alive and well.

Question 29

Review of Systems

Answer 29

A detailed, system by system assessment of past, resolved, and current health problems: * Health problems, past & present, system by system: * Examples: food intolerance, joint pain, orthopnea, menstrual history * Health maintenance practices: * Examples: dentist visits, self breast exams * Health promotion practices: * Examples: sunscreen, safety helmets "The purpose of this section is: 1. to evaluate the past & present health state of each body system, 2. to double check in case any significant data were omitted in the present illness section, & 3. to evaluate health promotion practices" Begins with general overview, including height & weight. ALWAYS look at the two together. Look at unplanned loss or gain.

Question 30

Guidelines for documentation

Answer 30

* Subjective data: ALWAYS use this format and quotes: * Patient states, “I have a stomach ache” * “yes”, “no”, or “none” * You rarely can use N/A (Not Applicable) unless it’s really not possible. * Example: menstrual cycle in a 2 year old girl or elderly man

Question 31

Guidelines for documentation

Answer 31

* Do: * Write neatly/ legibly, use black ink or type in EHR * Date and time at top of all notes * Proper spelling, terminology. * Only approved abbreviations * Quotes around anything said * STAY OBJECTIVE!!! * Be complete * No blanks. Do corrections as per institution policy * Sign “..SN, University of Massachusetts, Amherst”

Question 32

Guidelines for documentation

Answer 32

* Do NOT * Use biased statements, judge or offer opinions * Argue in chart * Suggest unsafe practice/ errors. Only subjective and objective data observed by you! * Use improper abbreviations * Use white-out

Question 33

SOAP

Answer 33

* Subjective: What you are told. Cannot OBSERVE this information * Objective: What you can see, hear, feel, smell, or measure, or can be quantifiably noted or measured * Assessment: Your impressions or conclusions are about the information you collected * Plan: What you plan to do with or about the information collected