Steps of health assessment

Steps of Health Assessment

Five key phases of assessment 1. Collecting data 2. Validating (verifying) data 3. Organizing data 4. Analyze the data 5. Identifying patterns/testing first impressions 6. 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 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 datasubjective data are data that are elicitedand verified only by the clientobtained through interviewing Maria Carmela L. Domocmat, RN, MSN

Includes Complete Health HistoryBiographical data Family health historyReasons for seeking Review of bodyhealth care systems (especiallyHistory of Present for current healthHealth concerns problems)Past health history 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 behavior measurement results of laboratory testing Maria Carmela L. Domocmat, RN, MSN

• Objective data are sometimes called signs,• Subjective data are sometimes called 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. 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. Maria Carmela L. Domocmat, RN, MSN

• Inferences – the nurse interpretation or conclusion based on the cues.• Example: red, swollen wound = infected wound; 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 1Mr. Michaels is 51 years old. He was admitted two days ago with chestpain. His physician has ordered the following studies: electrocardiogram,chest x-ray, and complete blood studies including a blood sugar. Thesestudies were just posted on the chart. When you talk with him, hestates, “I feel much better today – no more pain. It is a relief to get ridof the discomfort.” You think he appears a little tired or weary – heseems to be talking slowly and sighs more often than you would thinkis necessary. When his wife comes to see him, she is cheerful with him,but confides in you he seems depressed or something. His vital signsare: 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. Michaels2. List the objective data noted for Mr. Michaels Maria Carmela L. Domocmat, RN, MSN

The subjective data noted for Mr.MichaelsPatient states:◦ “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◦ Vital signs◦ Appears tired, weary◦ Patient’s age Maria Carmela L. Domocmat, RN, MSN

Case Study 2Mrs. Rochester is a 33 year old mother of two young children. She isadmitted 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 couldhave diabetes. No one in my family has diabetes. I feel fine—I don’t seehow 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 furtherquestioning, she admits she has been feeling unusually tired lately, andshe does seem to have to urinate more than usual. You check her chartand note her fasting blood sugar was elevated at 144. Her vital signsare: 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. Maria Carmela L. Domocmat, RN, MSN

The subjective data noted for Mrs.Rochester.◦ Patient states:◦ “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◦ Weight◦ Diagnosis of diabetes◦ Blood sugar◦ Vital signs Maria Carmela L. Domocmat, RN, MSN

Identify the client data as objectiveor subjective.Mrs. Jones says,” I can’t Mrs. Jones is breathing rapidly.sleep.”Client has a pulse of 104. The client states he has a hip fracture.Client states, “I am cold.” Surgical dressing is dry. Client says she cannot void.Client is coughing.Client walks with a limp. Wheezes are auscultated. Maria Carmela L. Domocmat, RN, MSN

Identify the client data as objective or subjective.__S__ Mrs. Jones says,” I can’t __O__ Mrs. Jones is breathing rapidly. sleep.”__O__ Client has a pulse of 104. __S__ The client states he has a hip fracture.__S__ Client states, “I am cold.” __O__ Surgical dressing is dry. __S__ Client says she cannot void.__O__ Client is coughing.__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 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 – 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 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 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 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 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. Maria Carmela L. Domocmat, RN, MSN

• Ways to cluster data: – Clustering data according to a nursing model – helps to identify nursing diagnoses and problems • 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 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. 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. Maria Carmela L. Domocmat, RN, MSN

• Assessment tools – Gordon’s Functional Health Patterns – Katz Index of Independence – 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• Cognitive-perceptual pattern• Self-perception-concept pattern• Role-relationship pattern• Sexuality-reproductive pattern• Coping-stress tolerance pattern• Value-belief pattern Carmela L. Domocmat, RN, MSN Maria

Analyze dataMaria Carmela L. Domocmat, RN, MSN

Analyze data• compare data against standard and identify significant cues. Standard/norm are generally accepted measurements, 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 pattern Maria Carmela L. Domocmat, RN, MSN

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. • 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, – 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 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 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 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 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• pinpoint findings by position on clock »left breast, dominant 3- cm mass at 1 oclock 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, and » the identification of medical problems that require immediate referral Maria Carmela L. Domocmat, RN, MSN

Steps of health assessment

by carmela Domocmat on Jun 25, 2011

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Steps of health assessment Presentation Transcript