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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.. Purpose of Assessment. To determine the client's functional abilities and the absence or pr
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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 clients functional abilities and the absence or presence of dysfunction.
Identification of the clients 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
Clients perception of health
Presence of health risk factors
Clients 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 clients 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
Clients 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 clients health history and current status in order to determine clients health needs.
Effective interviewing depends on the nurses knowledge and ability to skillfully elicit information from the client.
17. Interview Interview Preparation
Review of the clients 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
Gordons 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.