0133427269 Module34 Assessment LectureOutline

Module 34 Assessment  The Concept of Assessment Definitions Assessment ( systematic method of collecting data about a client Determine clients current and ongoing health status Predicting risks Identifying health-promoting activities Focus Problems presented by client Physical, social, cultural, environmental, emotional factors Four types of assessment ( see Table 34-1 TYPES OF ASSESSMENT, p. 2270 Initial or baseline Problem-focused Emergency Ongoing reassessment Types and sources of data Database ( contains all information about a client Types of data Subjective data (symptoms) ( apparent only to client and can be described or verified only by the client Examples itching, pain, feelings of worry Objective data (signs) ( detectable by an observer or can be measured or tested against an accepted standard May be seen, heard, felt, or smelled Examples vital signs, discoloration of skin Sources of data Primary source ( client Secondary sources ( family members, other healthcare professionals, laboratory tests Client ( best source of data Support people ( especially important for very young, unconscious, or confused clients Client records ( documentation by various healthcare providers Healthcare professions ( verbal reports from other healthcare providers Literature ( nursing and related literature can provide additional information Collecting data Principle methods Observation, interview, physical examination Nurses use all three methods simultaneously Observing Noticing the data Selecting, organizing, and interpreting the data ( see Table 34-2 USING THE SENSES TO OBSERVE CLIENT DATA, p. 2272 Interview Interview ( planned communication or conversation with a purpose Nursing health history ( see Box 34-1 COMPONENTS OF A NURSING HEALTH HISTORY Two approaches Directive interview ( highly structured and elicits specific information Nondirective interview ( rapport-building Planning the interview and setting Time Place Seating arrangement Distance Language Types of interview questions Open-ended questions Closed questions Neutral questions Leading questions See Table 34-2 SELECTED ADVANTAGES AND DISADVANTAGES OF OPEN-ENDED AND CLOSED QUESTIONS, p. 2274 Stages of an interview The opening The body The closing Case Study A ( Martha Whitman is a 59-year-old recently retired elementary school teacher complaining of continued acute back pain, p. 2276 Examining See Box 34-3 HEAD TO TOE FRAMEWORK, p. 2277 See Table 34-3 NURSING ASSESSMENTS ADDRESSING SELECTED CLIENT SITUATIONS, p. 2277 Preparing the client Preparing the environment Positioning ( Positioning See Table 34-4 CLIENT POSITIONS AND BODY AREAS ASSESSED, p. 2278 Consider clients ability to assume positions Minimize position changes Maximize comfort Methods of examining Inspection Visual examination Deliberate, purposeful, systematic Naked eye and lighted instrument(s) Palpation Using touch Determine Texture Temperature Vibration Position Distention Pulsation Presence of pain upon touch or palpation Light palpation Skin slightly depressed Deep palpation Done with one hand or bimanually Top hand applies pressure while lower hand remains relaxed Skin temperature Use dorsal aspect of hand and fingers Vibration Palmar surface of hand General guidelines Hands clean, warm, nails short Area of tenderness palpated last Deep palpation after superficial Assist client to relax ( increase effectiveness Percussion Act of striking body surface to elicit sounds Direct ( strike area to be percussed with pads of 24 fingers, or middle finger Strikes rapid, movement from wrist Indirect ( striking of an object held against the body Pleximeter/plexor Distal interphalangeal joint 5 types of sounds Flatness Dullness Resonance Hyperresonance Tympany Auscultation Listening Directunaided ear Indirectstethoscope 3035 cm long Internal diameter about 0.3 cm Amplifier placed firmly but lightly against skin Pitch ( frequency Intensity ( loudness Duration ( length Quality ( subjective ( whistling, gurgling, snapping Equipment ( see Table 34-7 TOOLS USED FOR A HEALTH EXAMINATION, p. 2281 Stethoscope Penlight Gloves Water-soluble lubricant Nasal speculum Ophthalmoscope Otoscope Percussion (reflex) hammer Tuning fork Vaginal speculum Cotton applicators Tongue blades Case Study B ( Clara and Roberto Galvez carry their screaming 7-year-old son Johnnie into the emergency department , p. 2282 Organizing data Maslows hierarchy of needs Physiological needs Safety and security needs Love and belonging needs Self-esteem needs Self-actualization needs Developmental theories Havighursts age periods and developmental tasks Freuds five stages of development Eriksons eight stages of development Piagets phases of cognitive development Kohlbergs stages of moral development Functional health patterns and body systems Immune system Respiratory system Cardiovascular system Nervous system Musculoskeletal system Gastrointestinal system Genitourinary system Reproductive system Validating data Validation ( act of double-checking or verifying data to confirm accuracy Ensure that assessment information is complete Ensure that objective and related subjective data agree Obtain additional information that may have been overlooked Differentiate between cues and inferences Avoid jumping to conclusions and focusing in the wrong direction to identify problems Interpreting data Determine If within normal limits for age, gender, race Determine significance of findings in relation to health status Knowledge Obtain, recall, and apply knowledge Access and use reliable resources Recognize situations that require Immediate attention Initiate care Seek appropriate assistance Nursing student Recall and apply knowledge to Discriminate between normal and abnormal Use resources Gain confidence and skill with experience and continuing education Case Study C ( James Long is a 46-year-old African American male , p. 2283 Communication Refers to exchange of information, feelings, thoughts, ideas Verbal techniques Accommodate language differences, difficulties, and so on Holistic approach Considering more than the physiological health status of a client Developmental factors Sources of information may vary Age Ability to communicate symptoms Disabilities Psychological and emotional factors Anxiety triggers autonomic response Physical problems can affect emotional health Family factors Family history of illness, health problems First-degree relative Family dynamics, circumstances Abuse, alcoholism Cultural factors Affect language, expression, and emotional, physical well-being Affect health practices Nurse must consider cultural norms Provide clear explanations Environmental factors Internal, external Consider findings in relation to norms for age, gender, race Data may provide cues about internal environment Diet affects color, consistency of stools External environmental factors Toxins inhaled Irritants Light, noise, motion Objects, substances encountered at home, school, or workplace Nursing practice Nursing care always begins with assessment Document findings in medical record as soon as possible Strong knowledge base and application of critical thinking Role multifaceted Review The Concept of Assessment Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 34.1 Holistic Health Assessment Across the Life Span Overview Nursing assessment requires the ability to interpret how the complex interactions of heredity environment and physiological, cognitive, and psychological development affect a client Special considerations for assessment of children Children are not little adults Head-to-toe approach may not work with young children Strong assessment skills Cognitive and verbal abilities differ Conduct nutrition history to establish rapport Anthropometric measurements, clinical observations appropriate for age Developmental milestones Length and weight Skinfold measurements Head circumference under 3 years old Age-specific percentiles Compared to age-matched peers Monitor growth over time Remain in same percentile over time Significant drop or increase cause for further investigation Overnutrition, undernutrition Caring, supportive firm approach Incorporate play if possible Encourage verbalization of fears No painful procedures in parents lap Children physically different from adults Ill child causes increased stress in parents May affect ability to recall information, follow instructions completely Written instructions Basic components of health history the same Ascertain relationship between child and adult with child Ask child about chief complaint May have to rely on caregiver present Caregiver may be stressed, sleep deprived Listen to caregiver, parent Call child by name Use words child understands Ask child to touch where it hurts 10 years old or above ( option of parent present Child is client, not parent Confidentiality Reporting requirements Allow children to touch medical equipment Elephant or cartoon character in ear Distract with toys See FOCUS ON DIVERSITY AND CULTURE Acceptable Child Behaviors Assessment specific to stages of the life span Comprehensive assessment includes subjective, objective data Physical growth and development change across life span Puberty period of rapid physiological growth and development Young adulthood marked by completed growth in physical, mental Middle age period with dramatic changes in physical development Health assessment includes body mass index (BMI), risks Activities of daily living (ADLs) Vision, hearing Cognitive, psychosocial, emotional development across life span Attachment essential in infant development Development of language and cognitive abilities in children Young adults expected to develop relationships, become productive Maturity and aging Assessment instruments Table 3410, INSTRUMENTS TO ASSESS GROWTH AND DEVELOPMENT, p. 2291 Assessment of infants Frequent assessments in first year ( monitor growth, development Accurate assessment combines History Physical assessment Knowledgeable observation Parent education Overnutrition, undernutrition identified by weight that crosses percentiles Cues for feeding Mixing of formula Head growth that crosses percentiles requires evaluation Hydrocephalus Parents, caregivers relay milestones, abilities Lagging may indicate inappropriate stimulation Knowledge deficit of caregiver, parent Healthy attachment observed Eye contact of parent and infant Observe for negative pattern Assessment of toddlers Rate of growth decreases, has expected pattern Assess caloric intake 24-hour recall of diet Discuss eating expectations, weight gain Health history often best way to assess ( cooperation unlikely from toddler Language assessment may be difficult ( toddler may not speak to stranger Playroom observation Exploration of environment ( safety concerns Tantrums Calm acceptance Observe caregivertoddler interaction Clinging unusual in nonthreatening situation Child looks to caregiver for comfort, support Caregiver attention/inattention Assessment of preschoolers Generally pleasant, cooperative, talkative Often less anxious if caregiver in view Will talk about activities ( assess language, cognitive ability, development Evaluate language, magical thinking, reality imitation Slowed rate of growth Clinging may indicate child who lacks trusting relationship Screening and interventions if child does not exhibit achievement of milestones Periodic health assessments Assessment of school-age children Slow, steady growth ( thin, gangly Evaluate diets to relieve family stress Appetite increases in older school-age child Anxious to talk about hobbies, friends, school, accomplishments Increasing neurological maturity Show off skills Families display pride Frequently sort, classify collections Industrious in school Positive feedback from families Open communication with adult family members Appropriate and much-needed limits Peer relationships becoming more important Child with no hobbies ( environmentally deprived Parents who speak of children as burden ( disturbed relationship Problems at school may evolve at this time Consistent place, time for homework Encourage communication Assessment of adolescents Eating generally not a problem ( increased appetite due to growth spurt Often communicate better with peers, nonfamily adults Assess together, then one-on-one Able to hold adult conversation Discuss school, friends, activities, future May be anxious about body, rapid changes Become more independent Parents anxious over evolving lack of control Uncomfortable with sexuality, dress, hair, values Severely restricting activities, freedom ( inhibits progress toward independence Assessment of young adults Busy, productive, healthy Intimate partnerships with others Cooperative, mature relationships May or may not involve marriage May be heterosexual, homosexual Childbearing choices Occupation chosen, values established Without steady job may lack direction, self-confidence Marital discord may trigger feelings of failure, insecurity Assessment of middle-aged adults Generally satisfied with past accomplishments Involved in activities outside the family End of childbearing, and most often childrearing Adjustment Older mothers Dissatisfied middle adult Unhappy with past Little or no hope for future Sedentary and isolated Assessment of older adults Functional assessment Systematic evaluation of older persons level of function and self-care Comprehensive geriatric assessment on regular basis AND Following hospitalization for acute illness, injury Nursing home placement, change in living status being considered After abrupt change in physical, social, psychological function Yearly for older person with complex health needs When older client or family would like second opinion Not all older adults need interdisciplinary team Incorporate holistic assessment techniques, standardized instruments into routine evaluations See Table 34-11 INSTRUMENTS FOR EVALUATION OF OLDER ADULTS, p. 2295 Comprehensive evaluations reduce hospital use, mortality rates Improve mental status, lower health costs Improve functional ability, lower hospital readmission rates Different perspective during geriatric assessment process Geriatrics and gerontology Issues of team dynamics Awareness of roles, contributions Excellent communication skills Conflict resolution skills Ability to see that multiple disciplines can provide critical information Three underlying principles of comprehensive geriatric assessment Physical, psychological, and socioeconomic factors interact Comprehensive evaluation of older persons health status Requires assessment in each domain Functional abilities should be central focus of comprehensive evaluation Foundation are traditional measures of health Medical and nursing diagnoses Physical examination results Laboratory results Interrelationships present challenge to nurse Evaluation of the assessment environment Instructions to family, client regarding parking, registration process Modifications ( lighting, accessibility, seating Accuracy of health history Packet prior to appointment Past medical history form Helpful for those with complicated medical histories Instructions to Bring all prescription, over-the-counter (OTC) drugs, herbals/supplements with them Bring medical records, reports, immunization records, health records Write down, bring names of all providers Primary care providers, specialists, alternative medicine providers History should include emphasis on Review of acute and chronic medical problems Medications Disease prevention, health maintenance review Functional status (ADLs) Social supports Finances Driving status and safety record Geriatric review of symptoms Memory Dentition Taste Smell Nutrition Hearing Vision Falls Fractures Bowel and bladder function Potential difficulties in obtaining health histories Communication difficulties Underreporting symptoms Vague or nonspecific complaints Multiple complaints Lack of time Social history Social support system Key elements Past occupation and retirement status Family history Present and former marital status Identification of family members Level of involvement Place of residence Current living arrangements Family dynamics Family and caregiver expectations Economic status, including adequacy of health insurance Social activities and hobbies Mode of transportation Community involvement and support Religious involvement and spirituality Spiritual assessment Collaborate with social worker Health insurance questions Functional evaluation Assess clients level of function and self-care Assess risk for falls Target self-care abilities, cognition, nutrition and feeding, continence, mobility, sleep, skin care Lifestyle and health considerations Well-adjusted older adults Maintain active lifestyle Involvement with others Often do not appear their age Older adults who have not successfully resolved developmental crises May feel life is unfair Despair and hopelessness may be evident Minimum Data Set (MDS) Assessment of older person for appropriate placement MDS comprehensive multidisciplinary assessment OBRA 87 ( all residents of facilities that collect payments from Medicare or Medicaid Must be assessed using the MDS Core set of screening, clinical and functional measures RAP ( Resident Assessment Protocols RUG( Resident Utilization Guidelines RAI( Resident Assessment Instrument Categories of data gathered for MDS include Client demographics and background Cognitive function Communication and heating Mood and behavior patterns Psychosocial well-being Physical function and ADLs Bowel and bladder continence Diagnosed diseases Health conditions (weight, falls, etc.) Oral nutritional status Oral and dental status Skin condition Activity pursuits Medications Need for special services Discharge potential Certain information may trigger need for further assessment ( RAPs Review Holistic Health Assessment Across the Life Span Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study 2015 by Education, Inc. 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