Week 3: health assessment vs. documentation

Question 1

understand the nursing process and the steps involved

Question 2

what role does critical thinking play in assessment and teh diagnostic process

Question 3

how is subjective data collected?

Question 4

how is objective data collected?

Question 5

describe the different sources of data

Question 6

what is the purpose of a client interview?

Question 7

when should closed-ended and open-ended questions be used?

Question 8

what cultural considerations are required in assessment?

Question 9

in what ways can nurses support indigenous peoples?

Question 10

what role does observation play in assessment?

Question 11

what role does diagnostic and laboratory data play in assessment?

Question 12

why is data validation important?

Question 13

why is analysis and interpretation important?

Question 14

describe some different types of nursing diagnosis help us with care planning?

Question 15

what are the 5 sources of diagnostic errors?

Question 16

how does nursing diagnosis help us with care planning?

Question 17

how can nurses set priorities

Question 18

what is a collaborative problem?

Question 19

What is ADPIE

Answer 19

the nursing process involves the steps of:

Assessment: what data is collected?

Diagnosis: what is the problem?

Planning: how to manage the problem?

Implementation: putting the plan into action?

Evaluation: did the plan work?

Question 20

what is assessment:

Answer 20

Assessment invovles discovery, decision making, critical thinking skills and data collection

Question 21

what are the main purpose of assessment?

Answer 21

• supplement, confirm or refute data obtained from history
• confirm or identify nursing diagnosis
• make judgements about health status and management
• evaluate outcomes

Question 22

what are we looking for in the preparation of assessment?

Answer 22

Gathering data: about client
- client health history
- family health history
- living situation
- family/ friend supports
- ADLs
- cultural & context

Question 23

The 3 main focuses on gethering data in assessment

Answer 23

1. main concern: it just depends; if in hospital ED or on ward, doctors office, PH (which vaccine), HH (specific needs) etc
2. health history: what other conditions does the client have? how could they impact care now?
3. specific care needs/ ALDs: independent vs. dependent, how do they eat or mobilize?, do they have any wounds?

Question 24

4 types of assessment

Answer 24

interview

emergency/ primary assessment

focused assessment

head-to-toe assessment

(depending on the type of assessment the preparation may be different)

Question 25

what is 2 data types?

Answer 25

subjective vs. objective feelings, perceptions & self-report vs. observations, measurements & verifiable facts

Question 26

what is subjective data?

Answer 26

: Feelings, perceptions & self-report (anything the clients was, feel, said) e.g. * the client reported 8/10 sharp, localized pain to their left flank * the client said they are feeling very anxious about surgery * the client was grimacing but denied any pain * the client said their dressing feels saturated

Question 27

what is objective data?

Answer 27

: observation, measurements & verifiable facts e.g. * the client has a temperature of 39.4 celsius * the client was grimacing but denied any pain * the client was found on the bathroom floor * the client is using accessory muscles * abdomen is distended

Question 28

what are the examples of primary/ secondary/ teritary data sources?

Answer 28

primary: directely collected= client secondary: family, physician, allied health PT/OT, Chart teritary: nurse experiences, literature

Question 29

what is primary data in assessment

Answer 29

* the ABCDE * the first assessment you will do when you meet your client * this is repeated whenever you suspect or recognize that your client's status has become or is becoming, unstable

Question 30

What does the ABCDE stand for?

Answer 30

Airway: #1 look for/ consider causes; consider immediate treatment Breathing: chest rise, work of breathing, RR, SpO2, auscultation - look for/ consider causes; consider immediate treatment circulation: skin colour, temp, pallor, cyanosis, diaphoresis, HR, edema * look for/ consider causes; consider immediate treatment disability: LOC, pain, ability to mobilize,s trength * look for/ consider causes; consider immediate treatment Environment/ exposure: equipment, safety, drains/ dressings, client needs * look for/ consider causes; consider immediate treatment ## Footnote - the first assessment you will do when you meet your client - this is repeand whenever you suspect or recognize that your client's stunts have been, or is becoming unstable

Question 31

what should be considered for safety in assessment

Answer 31

1. point of care risk assessment 2. infection control practices 3. falls prevention 4. UBCO scope of practice 5. BCCNM: BCCNM RN

Question 32

What are the skills of physical assessment for inspection

Answer 32

* visual check * position and expose body parts so all surfaces can be viewed * inspect for size, shape, colour, symmetry, position, drainage, & abnormalities * compare on eside with the other side (right hand & left hand) ## Footnote e.g. cyanosis, abdominal sitension, pallor

Question 33

What are the skills of physical assessment for auscultation

Answer 33

* use of stethoscope * familiarity with normal sounds first before identifying abnormal sounds or variations. * characteristics of sounds: frequency, loudness, quality, duration * requires concentration & practice

Question 34

What are the skills of physical assessment for palpation

Answer 34

* touch * assesses for tenderness, distension, masses * the nurse uses different parts of hands to distinguish texture, temperature, and movement * light palpation is generally enough * tender areas are palpated last

Question 35

What are the skills of physical assessment for percussion

Answer 35

* Client’s body is tapped with fingertips to produce a vibration​. * Sound indicates location, size, and density of structures​. * Used primarily by nurse 
practitioners & physicians 
in practice.

Question 36

what are the considerations with older persons

Answer 36

* Communication techniques. * Keep them warm. * Adjust as necessary. * Utilize knowledge of normal changes of ageing vs misconceptions. * Utilize knowledge of atypical presentations of illness. * Utilize knowledge of increased risks associated with infection and safety. ## Footnote - may take longer - may need rest periods - signs and symptoms may differ

Question 37

what is dianose in ADPIE

Answer 37

: analyze data collected in the assessment * identify helath problems, risks & strengths * formulate diagnostic statements * identify client needs

Question 38

what should nurses consider in the diagnose stage

Answer 38

* diagnostic label (approved by NANDA), * related factors (etiology), * definition of the label (approved by NADA), * risk factors (may increase vulnerabilities), * support for the statement (through assessment findings).

Question 39

what are the strategies for communicating effectively with older persons

Answer 39

1. Try to find a quiet room with minimal outside noises for communication 2. * Sit facing the patient so that they can watch your lip movement its and facial expressions 3. * If masks must be worn for safety, consider how to maintain an interaction that is warm, open and demonstrates interest in what the older person is saying 4. * If needed, make sure that glasses and hearing aids are being worn 5. * Speak slowly and clearly (do not speak loudly) 6. * Keep your tone of voice low; older persons can hear low-frequency sounds better than high-frequency sounds 7. * Periodically summarize what has been said to clarify that you have understood what the older person was saying, and repeat key points 8. * Ask the older person to explain what they understood and invite questions clarify information. There may also be cultural aspects related to communication 9. * Emphasize and integrate emotional and personal values in the acquisition of skills and ideas

Question 40

what are the 3 types od diagnosis

Answer 40

1. nursing diagnosis 2. medical diagnosis 3. collaborative problems

Question 41

what is nursing diagnosis

Answer 41

: A clinical judgement about client responses to an actual or potential health problem Nrsg focus: Treat/prevent Example: Ineffective airway clearance

Question 42

what is medical diagnosis?

Answer 42

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

Question 43

what is collaborative problem

Answer 43

: 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)

Question 44

examples of atypical presentation of illness in older populations

Answer 44

* Delirium (acute confusion) with an acute illness is considered a medical emergency * Depression without sadness * Infectious disease without fever or tachycardia * Myocardial infarction without chest pain * Nondyspneic pulmonary edema * Abdominal pain is absent or vague * Confusion is not inevitable. Look for neurological events, new medication, or the presence of risk factors for delirium * Many hospitalized older persons suffer from chronic dehydration accelerated by acute illness Not all older persons have fevers with infection; most common are respiratory or urinary tract infections. Symptoms may include increased respiratory rate, falls, incontinence, or confusion.

Question 45

NANDA

Answer 45

nursing diagnoses

Question 46

what is plan in ADPIE

Answer 46

where goals and outcomes are formulated that directly impact client's care

Question 47

what are involved in planning:

Answer 47

Set priorities establish client-centered goals. outcomes, select nursing interventions write a plan of care (PoC0 = consider short & long-term goals

Question 48

how the goals & outcomes made out from planning (the process)

Answer 48

circular: diagnosis -> medical & nursing goes to cleint expectations & health care expaecations or vice versa = goals & outcomes

Question 49

In the plan of Care, we need to look at HOW we help the client to meet these goals: what are those goals?

Answer 49

- Client to clear from confusion (long term goal) ○ complete CAM & PRISME. Treat P.R.N - Client will obtain acceptable levels of comfort (short term goal) ○ Scheduled analgesic. Offer before mobility - Risk of falls ○ Have PT/ OT assess. Up for meals. Mobilize TID.

Question 50

what is Implementation in ADPIE

Answer 50

carrying out or delegating nursing interventions

Question 51

what implementation includes all activities performed to:

Answer 51

* promote health * prevent complications * treat symptoms * facilitate coping

Question 52

implementation for acute confusion

Answer 52

main goal: client to clear from confusion * ensure PRISME assessed and appropriate interventions/ prevention is maintained

Question 53

implementation for acute pain

Answer 53

main goal: client will obtain acceptable levels of comfort * ensure medications given as ordered

Question 54

implementation for risk for falls

Answer 54

main goal: client to safely mobilize independently at home * ensure appropriate mobility TID, up for meals. follow PT and OT direction

Question 55

what is evaluation phase in ADPIE

Answer 55

process of comparing pt responses to preselected outcomes to determine whether goals have been met

Question 56

what are the expected activities in evaluation

Answer 56

* re-assess * evaluate * determine if outcomes have been met * continue, modify or terminate plan of care

Question 57

after implementation, check if the client is: ## Footnote (3)

Answer 57

clear from confusion comfortable had any falls

Question 58

what are the questions to avoid errors?

Answer 58

Do I understand the data? Did I collect all the relevant data? Have I accurately interpreted the information? How is my data organized? Have I considered other diagnoses? Do I need guidance? = develop critical thinking

Question 59

what is critical thinking in nursing?

Answer 59

“Nursing is a dynamic, continually evolving discipline that employs critical thinking to integrate increasingly complex knowledge, skills, technologies, and client care activities into evidence-based nursing practice. The goal of nursing for client care is preventing illness and potential complications; protecting, promoting, restoring, and facilitating comfort, health and dignity in dying.” (NCSBN, 2018).

Question 60

critical thinking involved priorities in nursing

Answer 60

Nursing diagnosis A: High urgency and importance: Client daughter yells that her mother cannot breath and they need a nurse’s help now Client needs assistance to get to the toilet Nursing diagnosis B: Low(er) urgency and importance: Client fell on the floor, is conscious and Client is very hungry for lunch and needs help to sit up at bedside Assessed based on Maslow’s hierarchy of needs: 1. psychological needs 2. safety and security 3. love and belonging 4. self-esteem 5. self-actualization

Question 61

Cultural Considerations and TIP

Answer 61

"do not impose personal values or beliefs" - 6 principles of TIP - 4Rs - respect - utilize therapeutic communication - cultures: ○ Age ○ Ethnicity ○ Status ○ Religion ○ Gender ○ Way of life

Question 62

Awareness of potential abuse

Answer 62

Client abuse - Neglect - Physical injury - Is there fear? - History Substances abuse - Missed appts - Excuses - GI bleeds or ulcers - CAGE

Question 63

Documentation:

Answer 63

◊ Client reported pain ◊ Client reported pain to the right shoulder ◊ Client reported 8/10 sharp pain to the right shoulder ◊ Client reported 8/10 sharp pain to the right shoulder, writer administere

Question 64

what is documented?

Answer 64

* Assessment findings * Diagnosis, often included in the plan of care * Implementations of interventions and evaluations of such : documents timely (7) and appropriate reports of assessments, decisions about client status, plans, interventions and client outcomes (BCCNM competency in standard 2: knowledge-based practice) AKA. Charting → Communication → Safe & appropriate care → Professional & legal standards : Protect yourself; but also ensure to protect other HCP through charting properly and safely (nurses don't like to be mentioned on charts e.g. their names)

Question 65

examples of documentation

Answer 65

* 24 hour flow sheet * Narrative nursing notes ○ Charting by exception ○ DAR-Data (assessment data), action (nursing intervention), response (evaluation) ○ Nursing care plans ○ Graphic sheets (vital signs) ○ Medication administration records (MARs) → Anything heard, seen, felt, or smelled should be reported accurately * Be objective * Avoid adding in your personal judgements → Subjective client information should be placed in quotation marks * Client reports "sharp" abdominal pain → Accurate terminology and abbreviations must be used * Only approved abbreviations should be used

Question 66

If a client has a fall a safety report is completed. What is the purpose of this safety report? 1. To have proper document in case of a law suit 2. To be a permanent part of the client's record (your response) 3. To inform family/ caregivers of what happened 4. To support quality improvement

Answer 66

4. To support quality improvement

Question 68

In which circumstances would a nurse document the MOST frequently 1. When a client is acutely ill 2. When a client is being discharged from the hospital 3. When a client is first admitted to the hospital 4. When a client has had a fall (your response)

Answer 68

1. When a client is acutely ill

Question 69

In which stage of the nursing process is documentation completed? 1. Assessment and planning 2. Implementation and evaluation 3. Assessment, planning 4. All of the stages (your response)

Answer 69

4. All of the stages (your response)

Question 70

During a morning assessment there is a situation with a client. Which of the following statements would be MOST appropriate? 1. Client became angry and frustrated with the nurse 2. Client was non-compliant and did not listen to the nurse 3. Client stated "get the fuck out of my room and leave me alone" (your response) 4. Client wanted to be left alone

Answer 70

3. Client stated "get the fuck out of my room and leave me alone" (your response)

Question 71

In which of the following situations is a nurse permitted to document care provided by another health care provider? 1. a client has a fall and another nurse helped them back to bed 2. a client is unresponsive and having a seizure and another nurse administered medications 3. a client resturned from surgery and another nurse changed their intravenous bag over 4. a client refused to take their medications from another nurse

Answer 71

2. a client is unresponsive and having a seizure and another nurse administered medications