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Chapter 16

Nursing Assessment

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Objectives

Describe the relationship between critical


thinking and nursing assessment
Differentiate between subjective and objective
data
Discuss methods of data collection
Discuss how to conduct a patient interview
Describe the components of the nursing history

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Five-Step Nursing Process

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Critical Thinking Approach


to Assessment

Assessment involves collecting information from


the patient and from secondary sources (e.g.,
family members), along with interpreting and
validating the information to form a complete
database.
Two stages of assessment:

Collection and verification of data


Analysis of data

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Critical Thinking Approach


to Assessment (Cont.)

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Case Study

Ms. Carla Thompkins, a 52-year-old


schoolteacher, is being admitted to the medicalsurgical unit as a postop patient recovering from
a below-the-knee amputation (BKA) secondary
to complications of type 2 diabetes.
Ms. Thompkins is admitted to the unit not only
so her recovery from the BKA may be monitored,
but also because she is going to receive
preliminary occupational and physical therapy to
help her adapt to the amputation.
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Developing the Nurse-Patient


Relationship for Data Collection

Sources of data

Patient (interview, observation, physical examination)


the best source of information
Family and significant others (obtain patients
agreement first)
Health care team
Medical records
Scientific literature

Database

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Types of Assessments

Types include

the patient-centered interview during a nursing health


history.
a physical examination.
the periodic assessments you make during rounding
or administering care.

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Types of Assessments (Cont.)

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Types of Assessments (Cont.)

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Types of Data

Subjective-this is what the patient tells you

Patients verbal descriptions of their health problems


Subjective issues cannot be verified by anyone

Objective- can be verified! This is what you see

Observations or measurements of a patients health


status; can be verified by other health care individuals

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Case Study (Cont.)

Yolanda is the student nurse who has been


assigned to admit Ms. Thompkins.
Yolanda enters Ms. Thompkins room, introduces
herself, and begins the admission health history
and physical assessment. During the
assessment, Ms. Thompkins complains of pain
at the incision site.

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Sources of Data

Patient
Family and significant others
Health care team
Medical records
Other records and the scientific literature
Nurses experience

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The Patient-Centered Interview

Motivational interviewing
Effective communication
Interview preparation
Phases of an interview

Orientation and setting an agenda


Working phase
Termination

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Interview Techniques

Observation
Open-ended questions
Leading questions
Back channeling
Direct closed-ended questions

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Nursing Health History

During the patientcentered interview


you will learn which
components of history
to explore

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Cultural Considerations

To conduct an accurate and complete


assessment, you need to consider a patients
cultural background.
When cultural differences exist between you and
a patient, respect the unfamiliar and be sensitive
to a patients uniqueness.
If you are unsure about what a patient is saying,
ask for clarification to prevent making the wrong
diagnostic conclusion.

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Quick Quiz!
1. A patient is admitted to the hospital with
shortness of breath. As the nurse assesses
this patient, the nurse is using the process of:
A. evaluation.
B. data collection.
C. problem identification.
D. testing a hypothesis.

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Components of the
Nursing Health History
Biographical
information
Reason for seeking
health care
Health history

Patient expectations
Present illness or
health concerns
Family history

Psychosocial history
Spiritual health
Review of systems

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Observation of Patient Behavior

It is important to closely observe a patients


verbal and nonverbal behaviors.

Adds depth to objective database

Observations direct you to gather additional


objective information to form accurate
conclusions about the patients condition.
An important aspect of observation includes a
patients level of function: the physical,
developmental, psychological, and social
aspects of everyday living.
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Nursing Health History (Cont.)

Diagnostic and laboratory data

Results provide further explanation of alterations or


problems identified during the health history and
physical examination

Interpreting and validating assessment data

Ensures collection of complete database


Leads to second step of nursing process

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Nursing Health History (Cont.)

Data documentation

Use clear, concise appropriate terminology


Becomes baseline for care

Concept mapping

Visual representation that allows you to graphically


show the connections among a patients many health
problems

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Case Study (Cont.)

Yolanda asks Ms. Thompkins a series of


questions about her pain, including:

Describe your pain to me.


Is the pain worse in the morning or in the evening?
Place your hand over the area that is uncomfortable.
Rate your pain on a scale of 0 to 10.

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Quick Quiz!
2. The nursing process organizes your
approach to delivering nursing care. To
provide care to your patients, you will need to
incorporate nursing process and:
A. decision making.
B. problem solving.
C. interview process.
D. intellectual standards.

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Case Study (Cont.)

Yolanda knows that the best source of


information regarding Ms. Thompkins care is the
surgeon.

Is this true? If not, then what is the best source


of data?

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