Evolution of Health Assessment in Nursing
- Florence nightingale : founder of modern nursing
- 1900s public health nursing came about
- 1950s Lydia Hall introduced the Nursing Process ( APIE). The Nursing Process focuses On assessing the Needs of the pt that. The nurse can identify and treat.
- 1960s Nurse practitioner immerged. The need for increased nursing skills for doing more comprehensive physical exam..
- 1970s expansion of specialties increase the need for assessment skills. Exam techniques and assessments began.
Confidentiality in nursing
Any information a patient relates will not be made available to others. The key is to protect the pt from exposure. But to provide enough data so that others may give constant care.
Critical thinking
The way a nurse process info using knowledge, past experience, intuition and cognitive abilities to formulate conclusion of a diagnosis
Critical thinking as part of the nursing assessment
Essential elements
- Keep an open mind
- use rational to support opinions and decisions
- show data to support
- understand the physiology of the “whys”
- use past clinical experience to build knowledge
- Aquire adequate knowledge base that continues to build
- be aware of your environment and interactions of others
Informed concent
The pt has been informed about the procedure, alternative treatment, ricks involved etc to make a decision about the procedure.
Five component of nursing process
(ADPIE)
- assessing the pt
- formulating a diagnosis
- planning nursing care
- implementation
- evaluate the effectiveness of care
Five component of nursing process
Assessing the pt
This is done by observing the patient and asking questions of the pt, family, and SO.
review the chart for assessment data, including diagnostic test, physician documentation, etc..
Assessing is done subjectively( things pt/family say. Symptoms ) and OBJECTIVELY( things you see, wounds, vitals, ski condition. Signs)
Five component of nursing process
Formulating the nursing diagnosis
This statement is describing an EXISTING or POTENTIAL health problem that nurses can treat separately from a physicians order. The health problem is based on the info collected during the assessment phase. To improve communication amount nurses and to assist in nursing research.
- Nursing assessment:
the first step of the nursing process. An ongoing systematic process of collecting and analyzing SUBJECTIVE and OBJECTIVE DATA to make critical judgment about health and life processes of individules, family and communities.
Appropriate client goals and goal objectives
Client goals
Steps of Data Analysis:
uses critical thinking process/reasoning skills to arrive at a nsg dx. The steps are:
- Identify abnormal data & strengths by doing assessment
- Cluster data
- Draw inferences & identify problems
- Propose possible nsg dx
- Check defining characteristics (the signs and symptoms)
- Confirm or rule out
- Document conclusions
Health Assessment Interview:
verbal interaction b/t (between) nurse & client for data collection. Interview is goal directed. Use therapeutic communication.
▪ 2 focuses of the interview:
* establish rapport to get accurate & meaningful information
* gather all info to identify deviations that can be treated with nsg & identify interventions that need to be done thru collaboration with other health care professionals
- Phases of the interview:
• Pre-interaction:
❖ Review chart, talk with staff, gather everything I need
• Introductory: ❖ Sets tone/direction, rapport, set expectations, listen ❖ Ensure comfort and privacy ❖ Assess non-verbals – pt’s actions – be mindful of my OWN non-verbal signals ❖ Be respectful • Working/Discussion: ❖ Most time consuming ❖ Collect relevant comprehensive data ❖ May not be done in one meeting
• Summary/Closure:
❖ End interview
❖ Summary to help validate – make sure nse and pt on same page.
Temperature Normal range
98.6 F( 96.4-99.1)
Or
37.0C ( 35.8-37.3)
Temperature terminology
Febrile
Increased /elevated temp (above normal)
Temperature terminology
Afebrile
No temp ( normal range)
Temperature terminology
Hyperthermia
Temp greater than 102.2F
- can lead to brain injury
Temperature terminology
Hypothermia
Temp between 77.0 and 95.0 F
Temperature terminology
Frostbite
Local hypothermia
Pulse
Indicates heart function and is the number of beats per minutes.
Needs arterial site to assess
Normal pulse rates
Adults 60-100 bpm
Child 80-100 bpm
Infant 100 bpm
Abnormal pulse rate
Tachycardia
Greater than 100bpm
Abnormal pulse rate
Bradycardia
Less than 60 bpm
Pulse:
Sympathetic nervous system
SA node
60- 100 bpm
Types of pulse
Radial
Apical
Apical/ radial
