CHAPTER 5 Assessment, Nursing Diagnosis, and Planning

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CHAPTER 5 Assessment, Nursing Diagnosis, and
Planning
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Assessment(Data Collection)

• During assessment, the nurse collects patient
  health data.
• Data are gathered on specific topics, organized
  into a database and documented.
• LPNs/LVNs may be asked to collect data as part of
  the assessment.
• (Contd)

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Assessment

• (Contd)
• There are various approaches to assessment
• Examples
• Functional health patterns assessment as
  formulated by Mary Gordon (see Table 5-1)
• Focused assessment (focuses on a specific
  problem)
• Basic needs assessment based on Maslows
  hierarchy of basic needs (see Figure 2-3)

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The Interview

• The interview is based on gathering data and is
  not a social interaction.
• Good communication is essential to performing an
  interview.
• Communication may be
• Verbal
• Non-verbal, noting body posture, facial
  expressions, movement, and gestures.
• (Contd)

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The Interview

• (Contd)
• Consists of three basic stages
• The opening, during which rapport is established
  with the patient
• The body of the interview, during which questions
  are asked to elicit data about the patients
  condition
• The closing, during which information is
  summarized

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Chart review

• Chart review should include
• Face sheet and physicians orders
• Nurses notes (at least the last 24 hours)
• Physicians progress notes and history and
  physical examination
• Medication administration record
• Surgery operative report, and pathology report
• Diagnostic tests
• Nursing admission history and assessment
• Nursing care plan

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The Physical Examination

• Performed after the admission interview
• A hands-on physical examination
• Gathering data concerning height and weight,
  vital signs, and information about each body
  system by performing inspection, auscultation,
  and percussion
• Objective data

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Head-to-Toe Assessment

• Should include
• Initial observation
• Breathing
• How the patient is feeling
• General appearance
• Skin color
• Affect
• (Contd)

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Head-to-Toe Assessment

• (Contd)
• Head
• Level of consciousness
• Awake, alert, and oriented
• Ability to communicate
• Language spoken, any communication deficits
• Mentation status
• Able to comprehend, form thoughts
• Appearance of the eyes
• Pupil size, light reaction
• (Contd)

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Head-to-Toe Assessment

• (Contd)
• Vital signs
• Temperature
• Pulse rate
• Rhythm, strength, apical, radial
• Respirations
• Rate, pattern, depth
• Blood pressure
• Within in normal limits
• Compare with previous readings
• (Contd)

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Head-to-Toe Assessment

• (Contd)
• Heart and lungs
• Heart sounds, normal S1-S2
• Lungs
• Lung sounds
• Rales, wheezes, diminished breath sounds
• Abdomen
• Shape, hardness, bowel sounds, last bowel
  movement, voiding, appetite, nausea
• (Contd)

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Head-to-Toe Assessment

• (Contd)
• Extremities
• Ability to move all extremities well
• Ability to move within normal range
• Skin turgor, color, temperature
• Peripheral pulses
• Edema
• (Contd)

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Head-to-Toe Assessment

• (Contd)
• Tubes and equipment
• Oxygen cannula, chest tubes
• NG tubes, PEG tubes, jejunostomy tube
• Urinary catheter
• Type and amount of drainage
• Dressings and drainage
• Pulse oximeter
• Traction devices
• Pain status

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Assessment in Long-Term Care/Home Health

• An initial assessment is performed on admission
  to long term care by the RN.
• Reassessment is performed at fixed intervals
  based on the patients condition.
• Medicare requires reassessment every 90 days.
• Home health assessments are usually performed by
  the RN on the initial visit and on each
  subsequent visit, depending on the patients
  condition.

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Nursing Diagnosis

• The nursing diagnosis is constructed to describe
• A health problem or potential health problem
  (see Table 5-4)
• An etiologic factor or factors (i.e., risk of
  injury related to neurologic impairment and
  muscle weakness)
• Used in acute care, long-term care and home
  health care

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PlanningGoals and Expected Outcomes

• ANA Standard IIIOutcome Identification
• Outcome identification requires individualized
  outcomes.
• An expected outcome is a specific statement of
  the goal the patient is expected to achieve as
  the result of a nursing intervention.
• Expected outcomes should be realistic and
  attainable and have a defined time line.

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Nursing Interventions

• Nursing interventions are nursing actions
  designed to alleviate problems and to achieve
  expected outcomes for the patient.
• Examples of nursing interventions include
• Monitoring high-risk problems
• Alleviating pain or discomfort
• Reducing stress
• Maintaining skin integrity

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Documentation

• The planning process is not complete until the
  plan has been documented and is part of the
  patients medical record.
• Plans constructed by LPNs/LVNs must be reviewed
  by the RN before they are placed in the chart.
• The plan of care should be reviewed and updated
  once every 24 hours.