3 Steps of Health Assessment -...

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Steps of Health Assessment

Transcript of 3 Steps of Health Assessment -...

Steps of Health Assessment

Five key phases of assessment

1. Collecting data2. Validating (verifying) data3. Organizing data4. Analyze the data4. Analyze the data5. Identifying patterns/testing first

impressions6. Reporting and recording data

Maria Carmela L. Domocmat, RN, MSN

Collecting data

• Subjective and Objective data– Aids critical thinking because each

complements and clarifies the other.– Subjective data – what the person – Subjective data – what the person

states verbally or in writing – Objective data – what you observe – S – S: Subjective = Stated– O – O: Objective = Observed

Maria Carmela L. Domocmat, RN, MSN

Collecting subjective data

�subjective data are data that are elicited and verified only by the client

�obtained through interviewing

Maria Carmela L. Domocmat, RN, MSN

Includes Complete Health History

�Biographical data�Reasons for seeking

health care�History of Present

�Family health history�Review of body

systems (especially for current health �History of Present

Health concerns�Past health history

for current health problems)

�Lifestyle and health practices profile

�Developmental level

Maria Carmela L. Domocmat, RN, MSN

Collecting objective data

• Data directly observed or detectable by the examiner or can be tested by using an accepted standard

Maria Carmela L. Domocmat, RN, MSN

Collecting objective data

• Data include:�physical characteristics�body functions

appearance�appearance�behavior�measurement�results of laboratory testing

Maria Carmela L. Domocmat, RN, MSN

• Objective data are sometimes called signs,

• Subjective data are sometimes called symptoms.symptoms.

Maria Carmela L. Domocmat, RN, MSN

• Subjective data: – States, “I feel like my heart is racing.”

• Objective data: – Pulse 150 beats, regular, and strong.– Pulse 150 beats, regular, and strong.

Maria Carmela L. Domocmat, RN, MSN

• The objective data support the subjective data: what you observe confirms what the person is stating.

Maria Carmela L. Domocmat, RN, MSN

• The subjective and objective data you identify act as cues.

• Cues are data that prompt you to get an initial impression about patterns of health or illness.

• The cues may lead you to infer (suspect).• Inference – the conclusion drawn about the cue: it

is how you interpret or perceive a cue.

Maria Carmela L. Domocmat, RN, MSN

• Cues – subjective or objective data observed by the nurse; it is what the client says, or what the nurse can see, hear, feel, smell or measure.feel, smell or measure.

Maria Carmela L. Domocmat, RN, MSN

• Inferences – the nurse interpretation or conclusion based on the cues.

• Example: red, swollen wound = infected wound; Dry skin = dehydratedwound; Dry skin = dehydrated

Maria Carmela L. Domocmat, RN, MSN

ACTIVITY

Maria Carmela L. Domocmat, RN, MSN

Subjective and Objective Data

• Read the following case studies and answer the subsequent questions.

Maria Carmela L. Domocmat, RN, MSN

Case study 1Case study 1

� Mr. Michaels is 51 years old. He was admitted two days ago with chest

pain. His physician has ordered the following studies: electrocardiogram,

chest x-ray, and complete blood studies including a blood sugar. These

studies were just posted on the chart. When you talk with him, he studies were just posted on the chart. When you talk with him, he

states, “I feel much better today – no more pain. It is a relief to get rid

of the discomfort.” You think he appears a little tired or weary – he

seems to be talking slowly and sighs more often than you would think

is necessary. When his wife comes to see him, she is cheerful with him,

but confides in you he seems depressed or something. His vital signs

are: T. 98.8, P: 74 and regular, R: 22; BP: 140/90. Maria Carmela L. Domocmat, RN, MSN

1. List the subjective data noted for Mr. Michaels

2. List the objective data noted for Mr. MichaelsMichaels

Maria Carmela L. Domocmat, RN, MSN

� The subjective data noted for Mr. Michaels

� Patient states:

◦ “No pain today”◦ “No pain today”

◦ Pain relieved - “feels relieved”

◦ Wife states he seems depressed.

Maria Carmela L. Domocmat, RN, MSN

� The objective data noted for Mr. Michaels

◦ Lab results

◦ Talking slowly

◦ Sighs◦ Sighs

◦ Vital signs

◦ Appears tired, weary

◦ Patient’s age

Maria Carmela L. Domocmat, RN, MSN

Case Study 2Case Study 2

� Mrs. Rochester is a 33 year old mother of two young children. She is

admitted with the medical diagnosis of diabetes. Today you enter room,

and she states, “The doctor says I have diabetes. I can’t see how I could

have diabetes. No one in my family has diabetes. I feel fine—I don’t see have diabetes. No one in my family has diabetes. I feel fine—I don’t see

how I can make myself change the way I eat. Dieting drives me crazy –

that’s why I weighed 190 pounds when you weighed me. On further

questioning, she admits she has been feeling unusually tired lately, and

she does seem to have to urinate more than usual. You check her chart

and note her fasting blood sugar was elevated at 144. Her vital signs

are: T: 98.10 F; P: 88 and regular; R: 24; BP: 144/88. Maria Carmela L. Domocmat, RN, MSN

1. List the subjective data noted for Mrs. Rochester.

2. List the objective data noted for Mrs. Rochester. Rochester.

Maria Carmela L. Domocmat, RN, MSN

� The subjective data noted for Mrs. Rochester.

◦ Patient states:

◦ “I can’t believe I have diabetes.”◦ “I can’t believe I have diabetes.”

◦ “I don’t think I can change eating habits.”

◦ Verbalization of feeling tired lately

◦ Increased urination is offered as a concern

Maria Carmela L. Domocmat, RN, MSN

� The objective data noted for Mrs. Rochester.

◦ 33 years old

◦ Mother of 2◦ Mother of 2

◦ Weight

◦ Diagnosis of diabetes

◦ Blood sugar

◦ Vital signs

Maria Carmela L. Domocmat, RN, MSN

Identify the client data as objective Identify the client data as objective or subjective.or subjective.

Mrs. Jones says,” I can’t sleep.”

Mrs. Jones is breathing rapidly.

Client has a pulse of 104. The client states he has a hip fracture.fracture.

Client states, “I am cold.” Surgical dressing is dry.

Client is coughing.Client says she cannot void.

Client walks with a limp. Wheezes are auscultated.

Maria Carmela L. Domocmat, RN, MSN

Identify the client data as objective Identify the client data as objective or subjective.or subjective.

__S__ Mrs. Jones says,” I can’t sleep.”

__O__ Mrs. Jones is breathing rapidly.

__O__ Client has a pulse of 104. __S__ The client states he has a hip fracture.fracture.

__S__ Client states, “I am cold.” __O__ Surgical dressing is dry.

__O__ Client is coughing.__S__ Client says she cannot void.

__O__ Client walks with a limp. __O__ Wheezes are auscultated.

Maria Carmela L. Domocmat, RN, MSN

Validation of data

• a crucial part of assessment that often occurs along with collection of subjective and objective data

Maria Carmela L. Domocmat, RN, MSN

Validation of data

• the act of “double-checking” or verifying data to confirm that it is accurate and complete.

Maria Carmela L. Domocmat, RN, MSN

Purposes of data validation:

• ensure that data collection is complete• ensure that objective and subjective data

agree• obtain additional data that may have been • obtain additional data that may have been

overlooked• avoid jumping to conclusion• differentiate cues and inferences

Maria Carmela L. Domocmat, RN, MSN

Validating (verifying) data

Maria Carmela L. Domocmat, RN, MSN

Validating (verifying) data

• Helps avoid:– Making assumptions– Missing pertinent information– Misunderstanding situations– Misunderstanding situations– Jumping to conclusions or focusing in the

wrong direction– Making errors in problem identification

Maria Carmela L. Domocmat, RN, MSN

• Guidelines:– Data that can be measured accurately can be

accepted as factual (e.g. height, weight, laboratory study resultslaboratory study results

– Data that someone else observes (indirect data) may or may not be true. When the information is critical, verify it by directly observing and interviewing the patient yourself.

Maria Carmela L. Domocmat, RN, MSN

– Validate questionable information by using the following techniques, as appropriate:

• Double-check that your equipment is working correctly

• Recheck your own data (e.g. take a client’s BP in • Recheck your own data (e.g. take a client’s BP in the opposite arm or 10 min later)

• Look for factors that may alter accuracy• Ask someone else, preferably an expert, to collect

the same data

Maria Carmela L. Domocmat, RN, MSN

• Double-check information that is extremely abnormal or inconsistent with patient cues (e.g. use two scale to check an infant who appears too much heavier or lighter, or appears too much heavier or lighter, or repeat extremely high or low lab result)

• Compare subjective and objective data to see if what the person is stating is congruent with what you observe

Maria Carmela L. Domocmat, RN, MSN

• Clarify statements and verify your inferences (e.g. “To me, you look tired”)

• Compare your impressions with those of other key members of the health care other key members of the health care team.

Maria Carmela L. Domocmat, RN, MSN

Organizing (clustering) data

Maria Carmela L. Domocmat, RN, MSN

Organizing (clustering) data

• Clustering the data together is a critical-thinking principle that enhances your ability to get a clear picture of the client’s health status.health status.

Maria Carmela L. Domocmat, RN, MSN

• Ways to cluster data:– Clustering data according to a nursing model– helps to identify nursing diagnoses and

problemsproblems• Henderson’s Components of Nursing Care• Gordon’s Functional Health Patterns• NANDA’s human response patterns• Maslow’s theories

• -

Maria Carmela L. Domocmat, RN, MSN

• Ways to cluster data:• Clustering data according to body systems

– helps to identify data that may indicate medical problemsmedical problems

Maria Carmela L. Domocmat, RN, MSN

• Note: It is important to do both in order to facilitate recognition of both possible nursing problems and medical problems.

Maria Carmela L. Domocmat, RN, MSN

• If you cluster data according to body system only, you are likely to miss key information that helps you identify nursing diagnoses. diagnoses.

Maria Carmela L. Domocmat, RN, MSN

• If you cluster data according to a nursing model only, you may group your data in such a way that medical problems may not be obvious. be obvious.

Maria Carmela L. Domocmat, RN, MSN

• Assessment tools – Gordon’s Functional Health Patterns– Katz Index of Independence– Barthel Index– Barthel Index– Newborn – APGAR Scoring System– Infants and Children – MMDST

Maria Carmela L. Domocmat, RN, MSN

Gordon’s Functional Health Patterns:

• Health perception-health management pattern.• Nutritional-metabolic pattern• Elimination pattern• Activity-exercise pattern• Sleep-rest pattern• Sleep-rest pattern• Cognitive-perceptual pattern• Self-perception-concept pattern• Role-relationship pattern• Sexuality-reproductive pattern• Coping-stress tolerance pattern• Value-belief pattern

Maria Carmela L. Domocmat, RN, MSN

Analyze data

Maria Carmela L. Domocmat, RN, MSN

Analyze data

• compare data against standard and identify significant cues. Standard/norm are generally accepted measurements, model, pattern:model, pattern:

Maria Carmela L. Domocmat, RN, MSN

Analyze data

• Ex: Normal vital signs, standard Weight and Height, normal laboratory/diagnostic values, normal growth and development patternpattern

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Identifying patterns/testing first impressions

Maria Carmela L. Domocmat, RN, MSN

Identifying patterns/testing first impressions

• After clustering data into groups of related information

• You get some initial impressions of patterns of human functioning. patterns of human functioning.

• But you must test these impressions and decide if the patterns really are as they appear

Maria Carmela L. Domocmat, RN, MSN

• Testing first impressions involves – deciding what’s relevant– making tentative decisions about what the

data may suggest, data may suggest, – focusing assessment to gain more information

to fully understand the situations at hand

Maria Carmela L. Domocmat, RN, MSN

• like the puzzle analogy – you put some of the puzzle pieces together and you think you know what the picture looks like

Maria Carmela L. Domocmat, RN, MSN

Reporting and recording data or Documentation of data

Maria Carmela L. Domocmat, RN, MSN

Reporting and recording data

• Reporting abnormal data in a timely fashion expedites diagnosis and treatment of urgent problems

• Recording data in a timely fashion • Recording data in a timely fashion promotes continuity, accuracy, and critical thinking

Maria Carmela L. Domocmat, RN, MSN

Documentation of data

• an important step of assessment because it forms the database for the entire nursing process and provides data for all other members of the health care teammembers of the health care team

Maria Carmela L. Domocmat, RN, MSN

Documentation of data

• thorough and accurate documentation is vital to ensure valid conclusions are made when the data are analyzed in the second step of the nursing process step of the nursing process

Maria Carmela L. Domocmat, RN, MSN

Documentation of data

• nurse records all data collected about the client’s health status

• data are recorded in a factual manner not as interpreted by the nurseas interpreted by the nurse

• record subjective data in client’s word; restating in other words what client says might change its original meaning.

Maria Carmela L. Domocmat, RN, MSN

Documentation of data

• use anatomic landmarks in descriptions• Ex: 1½ x 2 ½ wound located 2 ½ inches below the

umbilicus at the MCL

Maria Carmela L. Domocmat, RN, MSN

Documentation of data

• use anatomic landmarks in descriptions• Ex: 1½ x 2 ½ wound located 2 ½ inches below the

umbilicus at the MCL

Maria Carmela L. Domocmat, RN, MSN

Documentation of data

• pinpoint findings by position on clock»left breast, dominant 3-

cm mass at 1 o'clock position, 2 cm from the position, 2 cm from the areolar border

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

End result of assessment

• formulation of nursing diagnoses (wellness, risk, or actual) that require nursing care,

• the identification of collaborative problems that require interdisciplinary care, andthat require interdisciplinary care, and

» the identification of medical problems that require immediate referral

Maria Carmela L. Domocmat, RN, MSN