05.02 Nursing Process – Assess

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Overview

  1. Nursing Process – Assess
    1. Assessment
    2. Data Collection
    3. What we do with the data?
    4. Documentation

Nursing Points

General

  1. Assessment
    1. First step in the nursing process
    2. Different than just a physical assessment
    3. Data Collection
  2. Data Collection
    1. Subjective Data
      1. What the patient experiences or reports
      2. Examples: Pain, Nausea, Dizziness
    2. Objective Data
      1. What the nurse can see, observe, or quantify
      2. Examples: Vital Signs, Lab Values, Physical assessment
    3. Where do we get data?
      1. Directly from the patient
      2. From family
      3. From labs
      4. From a physical Head-To-Toe Assessment
      5. From other providers
      6. From the chart
  3. What we do with the data?
    1. Interpret it
      1. Gives insight as to what’s happening
        1. Sets up for Diagnosis of Nursing Process
      2. Compares normal to abnormal values
    2. Know normal values
      1. Have a good knowledge base
        1. Diseases
        2. Signs or Symptoms of disease
        3. Lab Values
        4. Medication doses
      2. Recognize critical events
  4. Documenting Assessment
    1. Differentiate between subjective and objective data
    2. Document objectively
      1. S: Pt states“I feel dizzy”
      2. O: Pt has unsteady gait
    3. Record facts
      1. Example: 1015 – Critical HGB called from lab – 5.5 mg/dL. Reported to provider MD Smith. Orders received, see EMR.

Nursing Concepts

  1. Professionalism
  2. Clinical Judgment

Reference Links

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Video Transcript

In this lesson, we’re gonna cover assessment or the first step in the nursing process.

Again, assess is the first step in ADPIE. When we assess, diagnose, plan, implement, evaluate, assess is the first phase in the nursing process. Now this is different than just a physical assessment. That’s what we might think of initially is like what we’re going to gather from physically assessing our patient. While a physical assessment is included in this, that’s not the only thing that we’re doing. We’re going to dive in a little bit more to some of the other ways we can get data and we can assess in this phase, so really is data collection.

When you think assess, I want you just to think of the term data collection. Data can be from a physical assessment, it can be from a chart, it can be from other places, and we’ll talk about that a little bit. We collect patient data. There’s two types of data we’re going to collect. The first is subjective. The second is objective, all right? Sometimes this can get a little bit confusing and sometimes you might be a little bit overwhelmed by “What’s subjective, what’s objective?” But let’s make it really simple for you. Subjective is something the subject reports does. It’s what the patient or the subject experiences or reports. Objective data is things that we can observe as the provider.

For subjective data, is things the patient says to us. Things like pain, nausea, dizziness, those are all subjective data points. Objective are things that we can see, observe and quantify. Things like vital signs and lab values or physical assessment. Think of these as like our five senses as a nurse. See, hear, touch, smell, taste. If it’s one of those things, then it’s objective data. It’s what we can observe versus subjective being what the subject reports to us.

There’s some other sources of data. Some other places we can get data would be like our physical assessment. Now we have an entire module and a bunch of lessons on physical assessment, so watch those to learn how to do a good physical assessment on your patient. We might see lab values, you also might see the monitor in your patient’s room, you might see the vent settings, you might see the dialysis settings, those are all … You might even see the height of a ventriculostomy drain, an EVD. You might see the settings on a different pressure machine, the height of the bed, whatever it is. Those are things that we can observe and see and chart. Then, you might also look in the patient’s chart for diagnoses, for charts from the physician, for any past notes from provider. This gives us an idea of the history of the patient.

We also might be able to get data from family members. Now, this is a really important data point that sometimes we can overlook, but this is especially helpful when a family member says she’s just not acting right or she’s not being normal. The patient is the best place for us to get baseline normal for our patient, and for things like neuro status and anxiety and things like that, the family is the best place to tell us what normal is for this patient. Another place we can get data is from other providers, the nurse who’s going off shift, a UAP, a provider, a physician, they can all give us data points as well.

What do we do with this data? Once we’ve collected all this data, what do we do? Well, we need to start interpreting it. Okay, this gives us insight into the patient’s problem, what’s going on, and as we begin to interpret this data that we’ve collected, that we’ve assessed, this starts to premise for the next step in the nursing process or the diagnosis phase, okay? Then we need to start comparing normal to abnormal.

This is where it becomes very important for you to know your normals. You really need to know normal values. You need to know what normal is for this disease. You need to know normal signs and symptoms of a disease process. You need to know normal lab values, you need to know normal medication doses, so this will come as you begin to gain more knowledge, but this is really important that as you’re learning that you’re focusing on these things. What is normal for diabetes? What is normal for an ischemic stroke? And then what are regular normal labs? What are regular normal doses? Okay. And once you know these normals, you can say, “Well, this patient isn’t doing these normals and we can start to interpret these things.” So it’s so important that you begin to learn the normals.

When you’re documenting, this is the assessment portion of the nursing process. What you want to do is, you really need to use quotes to describe what the patient says. Now let me show you how that would work with an subjective example and an objective example. If the patient states, “I feel dizzy,” that’s how you chart it in your chart. You write patient states, “I feel dizzy.” You don’t write in your chart. Patient is dizzy, okay? You need to put in quotes what the patient actually says and how they say it. Okay? For objective data, this is something that you see, so you just write. “Patient’s gait is unsteady.” That’s something that I can observe. I know what normal gait should look like. Patient doesn’t have normal gait. “I put patient gait is unsteady.”

Then you need to make sure you’re recording the facts. When documenting, record what you observe and always record factually. Something you could write would be like, “10:15, critical …” and ignore my handwriting here, “Critical hemoglobin called from lab,” write the lab value, “5.5 per deciliter and then reported to provider,” put the provider’s name, “MD Smith, orders received, see chart.” Now, this will all be typed into an electronic note, but see chart. We have a whole module on documentation, but this is kind of what it would look like. I’m being factual, I’m providing the time, I’m saying what happened, I’m writing the value that they gave, and then I’m saying what I did and what happened after that and where more data can come. That’s all very factual.

All right. Now, some of the nursing concepts that pertain to the assessment would be professionalism. We must be very professional in the way that we do this and this is kind of part of the way we work, and then clinical judgment. This is all about how we think on the floor and what we do with all the data is how assessment plays in.
Now, assessment in the nursing process is all about collecting data. When you hear assessment, I want you think data collection. Data collection comes from more than just looking at a chart. It comes more than just a health assessment, okay?

You must have a strong knowledge base. It’s so important that you have a strong knowledge base of normal values so that you can recognize abnormal values. This is so critical, and then we have subjective information and objective information. Subjective information is what the patient says they feel. Objective information is things that we can see or observe. Subject is just going to give us subjective information. Objective is things that we can observe.

Realize that there’s data everywhere. Nearly anything can be a data source when we’re assessing our patients. It can come from head to toe assessment, chart, family, the patient, lab values, and even from other providers, so don’t get stuck with trying to get something from one point. In our test taking course, we talked to you about how one of the biggest traps of the NCLEX nursing questions is incomplete assessment. Make sure that this assessment is complete, and that’s your whole role as the nurse, to get the complete, full, detailed assessment. Please always make sure that as many data sources are being collected as possible, especially when it’s you doing the assessment.

All right, guys. Make sure you check all the resource with this. Check out the other lessons that pertain to this and check out all the different assessment lessons, the head to toe assessment lessons, the test taking course, everything that pertains to this, all right? Now, guys, go out and be your best selves today and as always, happy nursing.

Read more

  • Question 1 of 10

A nurse is caring for a client who had surgery two days ago. The client has a peripheral IV in place. Which of the following should the nurse include as part of a standard assessment of the adequacy of this client’s IV? Select all that apply.

  • Question 2 of 10

A nurse is helping a client with his oral hygiene after eating breakfast in the morning. The nurse assesses the client’s ability to brush teeth and knows that lack of oral hygiene affects the client’s health. Which of the following situations is a risk for a client with poor oral hygiene?

  • Question 3 of 10

A nurse is utilizing the PQRST pain assessment method to determine if a client is experiencing pain. Which questions would the nurse ask according to the P portion of the assessment? Select all that apply.

  • Question 4 of 10

A client is brought to the emergency room with complaints of abdominal pain. The nurse performs a focused abdominal assessment. Which of the following is an element of the inspection portion of the exam? Select all that apply.

  • Question 5 of 10

A patient calls the nurse and complains about his IV site. The nurse assesses the site and notes that the skin is red and warm and the client states that the pain travels up his arm. Which of the following potential complications of IV therapy has most likely occurred?

  • Question 6 of 10

Prior to a client’s surgery, a nurse is assessing whether a PCA would be appropriate during the post-op period. Which factors would the nurse assess that would help determine that the use of a PCA is appropriate? Select all that apply.

  • Question 7 of 10

A nurse is caring for a client who is at high risk of dehydration. Which parameter would the nurse use to assess whether this patient is dehydrated?

  • Question 8 of 10

A nurse is assessing a 37-year-old client prior to administration of packed red blood cells for post-op hemorrhage. The nurse must use a pressure infusion device to rapidly administer the blood products. The nurse notes that the client has a 24-gauge catheter in her antecubital fossa. Which action of the nurse is correct?

  • Question 9 of 10

A child is brought into the emergency department with severe injuries. The physician orders a transfusion of one unit of whole blood to be administered immediately. The nurse has completed a rapid assessment of the child but there are no laboratory results available to know the child’s blood type. Which of the following actions of the nurse is most appropriate?

  • Question 10 of 10

A nurse is assessing a client’s ability to perform activities of daily living. Which action would the nurse have the client perform as part of this assessment process?

Module 0 – Fundamentals Course Introduction

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