NRSG 126 - Week 3 Flashcards
nursing assessment (54 cards)
Nursing process
ADPIE (Assessment, diagnosis, planning, implementation, evaluation)
Assessment
o Involves discovery, decision making, critical thinking skills, and data collection.
o supplement, confirm or refute data obtained from history,
o confirm or identify nursing diagnosis,
o make judgements about health status and management,
o evaluate outcomes
Gathering Data from…
o Client health history
o Family health history
o Living situation
o Family friend supports
o ADLs
o Cultural context
Assessment (1st step)
o The first step of assessment is preparation. Find out the client information. Look in:
o Client chart
o Meditech (online chart)
o Kardex
o During documentation (24-hour sheet)
gathering data
o Main Concern: it just depends! If in hospital ED or on
ward, doctors office, PH (which vaccine), HH (specific
needs) etc.
o Health History: what other conditions does the client
have? How could they impact care now?
o Specific Care Needs/ADLs: independent vs
dependent, how do they eat or mobilize?, do they have
any wound. The dependence level changes how we do things, different approach
assessment: data type - subjective and objective
o Subjective: Feelings, Perceptions & Self-report; The client reported 8/10 sharp,
localized pain to their left flank; the client said they are feeling very anxious, denied pain; the client said their dressing feels saturated; shortness of breath is a feeling so subjective,
o Objective: the client has a temperature of 39.4 Celsius; the client was found on the bathroom floor; The client was found on the bathroom floor; client is using accessory muscles; abdomen is distended (bloated)
o Only document what the client said or objective (not opinion)
Assessment types
o Interview
o Emergency/Primary assessment (in an emergency situation)
o Focused assessment (focusing on one issues)
o Head-to-toe assessment
o Depending on the type of assessment the
preparation may be different
data sources
o Primary – patient (best source)
o Secondary – family, physician, allied health (PT/OT), chart
o Tertiary – nurse, experience, literature
primary assessment
o The ABCDE
o The first assessment you will do when you meet
your client
o This is repeated whenever you suspect or
recognize that your client’s status has become, or
is becoming, unstable
Skills of Physical Assessment: Visual check
o Position and expose body
parts so all surfaces can be
viewed.
o Inspect for size, shape, colour, symmetry,
position, drainage, & abnormalities.
o Compare one side with the other side
(right hand & left hand)
o Document any concerns
ABCDE
o Airway: Look for/ consider causes; consider immediate treatment #1
o Breathing: Chest rise, work of breathing, RR, SpO2, auscultation. Look for/ consider causes; consider immediate treatment
o Circulation: Skin colour, temp, pallor, cyanosis, diaphoresis, HR, edema. Look for/ consider causes; consider immediate treatment
o Disability: LOC (go back to check airway, concerning), pain, ability to mobilize, strength. Look for/ consider causes; consider immediate treatment
o Environment/Exposure: Equipment, safety, drains/dressings, client needs. Look for/ consider causes; consider immediate treatment
Skills of Physical Assessment: Auscultation
o Use of stethoscope.
o Familiarity with normal sounds first before
identifying abnormal sounds or variations.
o Characteristics of sounds:
frequency, loudness, quality,
duration.
o Requires concentration &
practice
Skills of Physical Assessment: Percussion
o Client’s body is tapped with fingertips to produce
a vibration.
o Sound indicates location, size, and density of
structures.
o Used primarily by nurse
practitioners & physicians
in practice
Skills of Physical Assessment: Palpation
o Touch.
o Assesses for tenderness, distension, masses.
o The nurse uses different parts of hands to
distinguish texture, temperature, and movement
o Light palpation is generally enough.
o Tender areas are palpated last
medical diagnosis
o Medical diagnosis: The identification of a disease or condition on the basis of specific evaluation of signs and symptoms
Nrsg focus: Implement orders/monitor client
Example: Pneumonia
Assessment Considerations with Older Persons
o Communication techniques.
o Keep them warm.
o Adjust as necessary. (such as pain, pace take more time, give them breaks)
o Utilize knowledge of normal changes of ageing vs
misconceptions. (things take slower but they can still learn things)
o Utilize knowledge of atypical presentations of
illness.
o Utilize knowledge of increased risks associated
with infection and safety
o Document
Nursing diagnosis
potential health problem
Nrsg focus: Treat/prevent
Example: Ineffective airway clearance
Diagnose
o Analyze data collected in the assessment
Identify health problems, risks & strengths
Formulate diagnostic statements and identify
client needs.
o diagnostic label (approved by NANDA),
o related factors (etiology),
o definition of the label (approved by NADA),
o risk factors (may increase vulnerabilities),
o support for the statement (through assessment
findings
plan
o Where goals and outcomes are formulated that directly impact client care
o Involves:
o set priorities,
o establish client-centered goals/outcomes,
o select nursing interventions,
o write a plan of care (PoC)
o consider short- and long-term goals
collaborative problem
o Collaborative problem: An actual or potential complication that nurses monitor to detect a change in client status
Nrsg focus: Prevent and monitor for complications
Example: Potential complication of pneumonia – Sepsis (systemic
infection
plan of care
In the Plan of Care, we need to look at HOW we help the client to meet these goals
plan: acute confusion, pain, and falls risks
o Acute confusion: client to clear from confusion. Make sure the environment is safe
o Acute Pain: client will obtain acceptable levels of comfort. Giving pain medication.
o Risk of Falls: client to safety mobilize independently at home. Use of mobility aids, keep the bed locked rails up, working with PT, matts beside the bed, hip protectors
Implementation
Carrying out or delegating nursing interventions
o promote health,
o prevent complications,
o treat symptoms,
o facilitate coping
Implementation: Situation
o Acute confusion: Ensure PRISME assessed and
appropriate interventions/prevention is maintained
o Acute pain: ensure medications given as ordered
o Risk for falls: Ensure appropriate mobility TID, up for meals
o Follow PT and OT direction.
