Chapter 16: Nursing Assessment

Discuss the relationship between critical thinking and nursing assessment.
• Critical thinking = allows you to ask relevant questions and collect relevant history and physical assessment data related to a patient’s presenting health care needs
□ Vital part of assessment
□ Synthesize relevant knowledge
□ Recall prior clinical experiences
□ Meaningful and purposeful way

• Assessment = deliberate an systematic collection of information about a patient to determine the patients’ current and past health and functional status
-Collection of information from a primary source and secondary sources
-The interpretation and validation of data to ensure a complete database

What are the components of critical thinking.
knowledge, experience, attitude

Describe how developing relationships with patients fosters the assessment process.
Necessary for you to gather information to make accurate judgments about a patients current condition which you need to gain trust and respect

• Mobilizes hope for a patient and nurse

• Allows for an acceptable interpretation and understanding of illness, pain, fear, and anxiety

• Helps a patient use support from health care providers

• Shows interest in there problems and concerns which helps you collect relevant data

What is rounding and why is it helpful?
Set intervals allows you to address essential care needs and patients experiences

– Helps organize your workload unit

– Build trust with patients

– Increasing the likelihood that you will gain more information

-Communicate their health care problems more accurately and effectively

Describe the 4 C’s and how do they establish a foundation for patient assessment.
• Respect, good morals, introduce yourself, consent

• Privacy, good timing, avoid overtiring a patient

• Good first impression, open ended questions, seem interested, listen/attentive

*Summarize, clarification, restate

Differentiate between subjective and objective data.
• Subjective

– Patients verbal description of their health problem

– Include patients feelings, perception, and self-report of symptoms

– Only patients provides this information

• Objective

– Observations or measurements of a patient health status

-Measured on the basis of an accepted standard Ex. Thermometer, inches, rating scale

Explain ways to make an assessment patient centered and Discuss how to conduct a patient-centered interview.
Conduct = make patient realize they are the focus

• Relationship based and is an organized conversation focused on learning about the well and the sick as they seek care

• Discover details about concerns, explore expectations, and display genuine interest and partnership

*Form trust and effective long term therapeutic relationships

Describe the methods of data collection.
1. Patient
– Best source of information
– Learn through the eyes of patients about health care needs, cultural and lifestyle patterns, present/past illnesses..etc

2. Family and Significant others
– Picks up on things and aware of things the patient isn’t
– Confirms findings or identify patterns that a patient provides

3. Health Care Team
– Shift to shift communication (Hand-offs)
– Person of work care to other professionals (multidisciplinary)

4. Medical Records
– Compare and validate information

5. Others Records and Scientific Literature
– Scientific literature offers evidence to direct you on how and why to conduct assessments
– Education, military, and employment records often contain significant health care information

6. Nurse’s Experience
– Observe and experiences are source of data
-Probing to other nurses benefits

Describe the components of a nursing history.
• Biographical Information
• Chief concern or reason for seeking health care
• Patient expectations
• Present illness or health concerns
• Health history
• Family history
• Psychosocial history
• Spiritual health
*Review of Systems

Explain the relationship between data interpretation and validation.
• Interpretation
□ Determine the presence of abnormal findings
□ Meaningful and usable clusters
□ Ongoing data

• Validation
□ Comparison of data with another source to determine accuracy
□ Discover the real reason
□ Opens the door for gathering more assessment data
*Involves clarifying vague or unclear data

Identify interview techniques
• Observation

• Open Ended Questions

• Leading Questions

• Back channeling

• Probing

• Direct Closed Ended Questions

What is the difference between data collection and data analysis?
Data Collection = getting information about the situation

Data Analysis = understanding data and compare findings

Describe Observation
Nonverbal, body language, tone of voice

Describe Open Ended Questions
– Hear flaws and feelings
– No straight forward answers
-Leads to discussions

Describe Leading Questions
Possibly limiting information to what a patients thinks you want to know

Describe Back channeling
– Reinforce your interest
-Active listening prompts more interest

Describe Probing
– Full description without trying to control the direction the story takes
– Opened ended questions
-Stay observant

Describe Direct Closed Ended Questions
– Either yes or no responses
-Fully describes and identifies specific problems areas

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