Assessment

1. Chapter 11 Assessment

2. Assessment Assessment is the first step in the nursing process and includes systematic collection, verification, organization, interpretation, and documentation of data for use by health care professionals.

3. Purpose of Assessment To determine the client�s functional abilities and the absence or presence of dysfunction. Identification of the client�s skills, abilities, and behaviors available to promote treatment and recovery. Establish a therapeutic relationship.

4. Types of Assessment Comprehensive Assessment Focused Assessment Ongoing Assessment Emergency Assessment

5. Comprehensive Assessment Usually completed upon admission. Provides baseline data: Physical and psychosocial aspects Client�s perception of health Presence of health risk factors Client�s coping patterns

6. Focused Assessment Limited in scope in order to focus on a particular need or health problem. Less detailed. Health care agencies in which short stays are anticipated.

7. Ongoing Assessment Systematic monitoring and observation related to specific problems. Database is broadened or confirmed. Determine client�s response to nursing interventions. Identify any emerging problems.

8. Ongoing Assessment Home care nurses using ongoing assessments must direct the client to provide information relevant to the current problem.

9. Emergency Assessment A rapid assessment of clients experiencing life-threatening problems or crises. Problems can be of physiological and/or psychological and sociological nature.

10. Data Collection Uses cognitive, interpersonal, and technical skills to elicit appropriate information. A variety of sources and methods are used in compiling a comprehensive database.

11. Types of Data Subjective Client�s perception, feelings, opinions, concerns Also referred to as symptoms Cannot be readily observed by others

12. Types of Data Objective Observable, measurable (quantitative) Also referred to as signs Standard assessment techniques Laboratory and diagnostic testing

13. Sources of Data Primary Client

14. Sources of Data Secondary Family/Significant other Other health care professionals Medical records Rounds Diagnostic tests Literature sources Nursing knowledge

15. Methods of Data Collection Observation General appearance and behavior of the client Nonverbal cues may indicate pain, anxiety, anger or physical changes.

16. Methods of Data Collection Interview Collection of information about the client�s health history and current status in order to determine client�s health needs. Effective interviewing depends on the nurse�s knowledge and ability to skillfully elicit information from the client.

17. Interview Interview Preparation Review of the client�s medical records Communication with other health team members Research of the presenting medical diagnosis

18. Interview Preparation Provide privacy Promote comfort Minimize distractions and interruptions Maintain comfortable room temperature and adequate lighting Establish time guideline for interview

19. Interview Stages Introduction Working Closure

20. Interview Stages Introduction Stage Beginning of a nurse-client relationship. Introductions are made. Establishes rapport. Defines roles. Explains purpose and use of data.

21. Interview Stages Working Stage Focuses on data collection. Questions move from general to specific. Closed-ended questions yield brief answers. Open-ended questions encourage the client to elaborate about a particular concern. Focused questions obtain more information about a specific problem or condition.

22. Interview Stages Closure Stage Nurse summarizes data. Asks for validation.

23. Health History Demographic Information Reason for Seeking Health Care Perception of Health Status Previous Illnesses, Hospitalizations, Surgeries Client/Family Medical History

24. Health History Immunizations/Exposure to Communicable Disease Allergies Current Medications Developmental Level

25. Health History Psychosocial History Value and Belief System Sociocultural History Activities of Daily Living Review of Systems

26. Physical Examination Baseline Data Assessment Techniques Inspection Palpation Percussion Auscultation

27. Physical Examination

28. Laboratory and Diagnostic Data Objective data that serve as defining characteristics for various altered health states. Effectiveness of interventions and progress toward health restoration are often monitored through test data.

29. Data Verification The process by which data are validated as complete and accurate. Data are reviewed for inconsistencies or omissions. Subjective and objective data are examined for congruence. Findings should be compared with norms.

30. Data Organization Data clustering is organization of the information in order to identify strengths and weaknesses. How data is clustered depends on the assessment model used.

31. Data Organization Assessment Models Nursing Models Non-Nursing Models

32. Assessment Models Nursing Models Gordon�s Functional Health Patterns Human Response Pattern Theory of Self-care Roy Adaptation Model Leininger Sunrise Model

33. Assessment Models Non-Nursing Assessment Models Body Systems Model Hierarchy of Needs

34. Data Interpretation Data clustering facilitates recognition of patterns and determination of further data that is needed. Data interpretation is necessary for identification of nursing diagnoses.

35. Reporting and Documentation Documentation is the basis for determining quality of care. Should include appropriate data to support identified problems.

36. Data Interpretation Types of Assessment Database Formats Open-Ended Formats Checklist Formats Combination Formats Specialty Formats

37. Specialty Formats The MDS Medicare Prospective Payment Assessment Form (MPAF) Developed by the Health Care Financing Administration (currently CMS). Used in all skilled and long-term care facilities that are funded by CMS.