What Information Needs to Be Collected during a Nursing Assessment and How Can the Nursing Care Plan Be Evaluated - Coursework Example

A. ‘What information needs to be collected during a nursing assessment and how can the nursing care plan be evaluated?’ A comprehensive health assessment, in holistic nursing, encompasses the physical, psychological, social and spiritual dimensions of a person. Physical health includes basic functions such as breathing, eating and walking. Psychological health includes intellect, self-concept, emotions and behaviors. Social dimensions of health involve relationships and interactions among family members, friends and co-workers. Spiritual health encompasses belief in a higher being, personal interpretation of the meaning of life, and attitudes toward moral decisions and personal conduct. Therefore, in health assessment, the nurse must consider all of these dimensions. Whereas, nursing assessment is a component of the nursing process, according to Kozier, et al (2004), it is the systematic collection, organization, validation and documentation of client data for the purpose of establishing a database about the patient’s response to health concerns or illness and the ability to manage health care needs. Assessment is the first step in the nursing process which is and is one of the most important most important procedures conducted by nursing staff. It is the nurse that is responsible for assessing the patient for problems or care needs; determining when those findings require the attention of a nurse, physician, or other professional; informing the appropriate persons of the findings; and ensuring follow up for the patient. Since assessment is the very basic in the entire cycle of the nursing process, it is important that the assessment should be correct and complete as this provides the baseline that the diagnosis is based on, the plan of the nursing care shall be identified, the specific interventions be applied, and the evaluation of goals if met or unmet be realized. Incorrect assessment will lead to incorrect diagnosis and ineffective nursing care process that will not satisfy patient’s health care and nursing needs. Kozier (2004) states that assessing a client’s health status is a major component of nursing care and has two aspects: (1) the nursing health history and (2) the physical examination that can be any of the three types namely: (a) a complete assessment (when a client is admitted to a health care agency), (b) examination of a body system (e.g., the cardiovascular system) and (c) examination of a body area (e. g., the lungs, when difficulty with breathing is observed). The complete body of information about the patient is called the patient data base. If the patient is newly admitted in a health care agency, a complete assessment shall be conducted but at times, it may be necessary to perform a focused specific assessment instead of a complete assessment in cases of already admitted patients. For example, a patient may be ambulated and he may complain about being constipated. A complete history and physical assessment at this time may not be in detailed form because that has already been done. However, the nurse can focus on the problem of constipation and find out how long it has been going on, the last bowel movement, the characteristics of the bowel movement, any pain the patient may be having, what factors contributed to the constipation, the clients diet and fluid intake, and his usual treatment for constipation. Two types of data are being gathered during nursing assessment. First is the subjective data (symptoms) or those that can be described only by the person experiencing it. Examples of these data are itching, pain, and feelings of worry. Relevant data regarding symptoms are: Location (area of the body in which symptom, such as pain, is felt), Character (the quality of feeling or sensation, e.g. sharp, dull, stabbing), Intensity (the severity or quantity of the feeling and its interference with functional ability), Timing (onset, duration, frequency, and precipitating factors of the symptoms), Aggravating/Alleviating Factors (activities or actions that make the symptom better or worse). Subjective data include the client’s sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situation. Second is the objective data or those that can be observed and measured or tested against an accepted standard (e.g., vital signs, pallor, diaphoresis, and reddish urine). They can be seen, heard, felt, or smelled and they are obtained by observation or physical examination. Data is collected by way of interview, physical examination, and review of records. Review of Records Before interviewing the client and conducting a physical examination, it is important to review the patients records to gather information about the client’s nursing health history. This can be done by checking the admitting performer, the medical staffs’ history and physical examination, any progress or nursing notes and the current medical orders if available. This will provide background information and help identify the research needed to do to better understand the patients problem. It will also prevent the patients having to answer the same basic questions repeatedly. The Interview Many subjective data are gathered through interview. According to Heath (2005), the interviewing process as described in Potter and Perry’s Foundations in Nursing Theory and Practice (2005) provides a good overview of communication skills. Communication skills are essential to eliciting data relevant to the patients care. Daniels (2004), points out that the better prepared you are for the interview, the better your chances of asking something relevant and revealing that provides new insight about the patient. Also stated on the book is that the better listener you are, the better the chance of hearing something meaningful and the more perceptive you are, the better your chances of seeing new relationships among the data collected. As the client is being interviewed, it is important to follow a plan in order not to omit anything. Once interview data were collected, it is important to record it legibly in an organized and timely way. It is easy to forget important details and there is no problem with taking notes while interviewing the patient. Those parts of the client’s nursing health history not gathered through review of records can be obtained through interviewing the client himself (as the primary source of data), family members, other support persons, or other health professionals. The subjective data in assessment are usually gathered through interviewing the client. Nursing-nurse.com (Anon 2007) has the following inclusions as a standard for assessment to be asked from the client : (1) Biographic Data - Includes client’s name, address, age, sex, marital status, occupation, religious preference, health care financing, and usual source of medical care. (2) Chief Complaint or Reason for Visit - The client’s answer to the question “What brought you to the hospital?” or “What is troubling you?” is expressed in the client’s own words. (3) History of Present Illness - This includes the onset of symptoms, when the symptoms started, if its development was sudden or gradual, severity and frequency of occurrence, the site or exact location of distress; the character of the complaint, its intensity or quality of discharge, sputum, etc.; activity of the client which may be involved in the development of the problem, phenomena or symptoms associated with the chief complaint, and the factors that aggravate or alleviate the problem. (4) Past History - This includes childhood illnesses such as chickenpox, mumps, measles, rubella or German measles, rubeola or red measles, streptococcal infections, scarlet fever, rheumatic fever, and other significant illnesses; immunizations and the date of the last tetanus shot; allergies to drugs, animals, or other environmental agents and the type of reaction that occurs; accidents and injuries (how, when, and where the incident occurred, type of injury, treatment received, and any complications); hospitalizations for serious illnesses (reasons for the hospitalization, dates, surgery performed, course of recovery, and any complications); and medications currently used as well as over the counter medications such as aspirin, nasal spray, vitamins or laxatives. (5) Family History of Illness - This is to ascertain risk factors for diseases. Particular attention should be given to disorders such as diseases of the heart, tuberculosis, cancer, diabetes, hypertension, obesity, allergies, arthritis, bleeding, alcoholism, and any mental disorders. (6) Lifestyle - This includes personal habits (the amount, frequency, and duration of substance use like tobacco, alcohol, coffee, cola, tea, and illicit or recreational drugs); diet (description of a typical diet on a normal day or any special diet, number of meals and snacks per day, who cooks and shops for food, ethnically distinct food patterns, and allergies); sleep/ rest patterns (usual daily sleep/wake times, difficulties sleeping, and remedies used for difficulties); activities of daily living or ADLs (any difficulties experienced in the basic activities of eating, grooming, dressing, elimination, and locomotion); instrumental activities of daily living (any difficulties experienced in food preparation, shopping, transportation, housekeeping, laundry, and ability to use the telephone, handle finances, and manage medications); and recreation or hobbies (exercise activity and tolerance, hobbies, and other interests, and vacations). (7) Social Data - This pertains to quality of family relationships/friendships (the client’s support system in times of stress, what effect the client’s illness has on the family, and whether any family problems are affecting the client); ethnic affiliation (health customs and beliefs, cultural practices that may affect health care and recovery); educational history (data about the client’s highest education attained and any past difficulties in learning); occupational history (current employment status, the number of days missed from work because of the illness, any history of accidents on the job, any occupational hazards with a potential for future disease or accident, the client’s need to change jobs because of past illness, the employment status of spouse or partners and the way childcare is handled, and the client’s overall satisfaction with the work); economic status (information about how the client is paying for medical care and whether the client’s illness presents financial concerns); and home and neighborhood conditions (home safety measures and adjustments in physical facilities that may be required to help the client manage in physical disability, activity intolerance, and activities of daily living, the availability of neighborhood and community services to meet the client’s needs) (8) Psychological Data - These are major stressors experienced by the client and their perception of them, the usual coping pattern with a serious problem or a high level of stress, and the communication style (the ability to verbalize appropriate emotion and nonverbal communication such as eye movements, gestures, use of touch, and posture, and the ability to interact with support persons, and the congruence of nonverbal behavior and verbal expression. (9) Patterns of Health Care - Includes all the health care resources the client is currently using and has used in the past. These are the family physician, specialists, dentists, folk practitioners, health clinic, or health center – whether the client considers the care being provided adequate and whether the access to healthcare is a problem. Physical Examination The physical examination is usually done after interviewing the patient and some rapport had been established. It is important to explain the purpose of the examination and the uses of the information. Nonverbal objective cues and verbal interactions are very important to be observed at this point. Introduction of the nurse at the beginning of a physical assessment enhances the ability to accomplish the complete assessment. It may be frightening to the patient to see a nurse who lacks self-confidence while conducting the assessment. According to Heiseman (2008) the patients general appearance and health state in relation to his age and lifestyle during physical examination shall be observed. For posture and gait, observe whether the patient is erect or slouched, steady or unsteady. Posture can indicate mood. For example, a slumped position may reflect depression; too rigid and upright a position may indicate anxiety. For Hygiene and grooming, look for cleanliness of nails, hair, skin, and overall appearance. Usually, you can assess these gradually while observing other parts of the body for data. Observe the skin for color, texture, temperature, and lesions. Lesions warrant particular attention during assessment. For the actual hands-on examination with the patient, the vital signs are first gathered (temperature, pulse, respiration, and blood pressure). Myers (2003) included HEENT as part of the physical examination – Head (H), assess the condition of hair and scalp, and the symmetry of face; Eyes (E), appearance of conjunctiva and sclera as normal in color and hydrated and use PERLA (pupil size, equality, roundness, light reaction/response, accommodation) in assessing the pupils; Ears (E), check hearing aids, impairment, pain, and drainage; Nose (N), assess congestion, drainage, and sense of smell; and on the Throat (T), check for dentures, mucous membranes if pink and hydrated, odor, hygiene, JVD, tracheal alignment, and retractions. After the HEENT, the head-to-toe assessment is then performed using the specific techniques of inspection (thorough visual observation), palpation (touching to assess texture, temperature, moisture, organ location and size, swelling, etc.), percussion (short tapping strokes on the surface of the skin to create vibrations of underlying organs) and auscultation (listening to sounds in the body created by movement of air or fluid). Neurological assessment focuses on level of consciousness, pupil response, hand grasps, and foot pushes. When describing a client’s affect, the nurse must utilize terms that are descriptive of the specific behavior observed, not the nurse’s judgment about the behavior. Thoracic assessment focuses on cardiovascular and respiratory status, wounds, scars, drains, tubes, dressings, and the breasts. Abdominal assessment focuses on gastrointestinal and genitourinary status and includes use of inspection, auscultation, percussion, and palpation within the four quadrants of the abdomen to establish bowel function and status. For musculoskeletal and extremity assessment, knowledge of the symmetry and strength of muscles can be obtained through observation of client gait and overall range of movement. And finally for assessing the skin, check for the following characteristics as to color (cyanosis, redness, pallor, jaundice), temperature (coolness, warmth), moisture (diaphoresis, excessive dryness), turgor (the time it takes the skin to flatten out after pinching a section on top of hand – poor skin turgor may indicate dehydration), edema (edema of extremities, sacrum, dependent side if patient is debilitated and confined to a bed or chair, facial/sclera, bilateral versus unilateral) and lesions (presence and type of skin lesions). After conducting the complete patient assessment, all data gathered shall be critically analyzed, organized, validated and documented. Ability to identify significant cues and make correct inferences is based on observation skills, knowledge base, and clinical expertise and these skills are developed continually. Most of the healthcare facilities nowadays are using a clinical assessment form/guide with ready-made questions to be followed. Doenges’ book entitled Nursing Care Plans has this sample format of the assessment guide. Some sample clinical forms are available on the internet like the AORN Sample Patient Record, BAI Clinical Forms and Procedures, and Clinical Nurse Assessments (all web page links for these forms are cited on the reference section). Evaluation of the Nursing Care Plan Evaluation is the fifth and the last phase in the nursing process. Evaluating is a planned, ongoing, purposeful activity in which clients and health care professionals determine the client’s progress toward achievement of goals/outcomes and the effectiveness of the nursing care plan. According Doenges, in her book entitled Nursing Care Plans (2002), the well-written plan or care communicates the patient’s past and present health status and current needs to all members of the healthcare team involved in providing care. The nursing care plan provides a mechanism to help ensure continuity of care when the patient leaves a care setting while still needing services. Evaluation of the care plans is an important part of the nursing process because conclusions drawn from the evaluation determine whether the nursing interventions should be terminated, continued or changed. Evaluation goes on continually while the patient is being taken cared of. Patients response will be determined to a variety of interventions and there may be changes that need to be made in the approach being taken taking. This type of evaluation helps identify problems and make changes early before completing the days work. It is also necessary to evaluate whether the problem is still accurate and relevant, whether the outcomes are still realistic, and whether the plan of care in general is satisfactory. In addition to this type of evaluation, an outcome evaluation is necessary to be conducted. This type of evaluation involves a determination of: (1) The patients response to the interventions you performed; (2) Whether expected outcomes were met, not met, or partially met; (3) Factors affecting the achievement of the outcomes; and (4) Whether to change, modify, or terminate the plan of care. Although the word "evaluation" may conjure up negative ideas, evaluation is actually a constructive process because it provides feedback, promotes problem solving, and promotes personal growth. Several possible reasons could result to an unmet outcome. Some of the reasons for failure to meet expected outcomes include: (1) Changes in the patients condition that supersede the plan of care; (2) The need for more time to see if the outcome can be met; (3) Gaps in assessment data; (4) Errors in identification of problems or nursing diagnoses; (5) Unrealistic or vague expected outcomes and plans; and (6) Lack of patient input in the plan of care. In the evaluation, these factors should be considered and any changes for recommendation in the plan of care shall be noted. In an article by Sox entitled ‘What is A Care Plan?’ she states that the purpose of the care plan is to guide all who are involved in the care of this person to provide the appropriate treatment in order to ensure the optimal outcome during his/her stay in our healthcare setting. A caregiver unfamiliar with the patient/resident should be able to find all the information needed to care for this person in the care plan. Some guide questions that will aid the healthcare provider to further evaluate the plan of care for the patients. In such case where upon providing proper nursing care for patients still the problem is not likely to improve or resolve (particularly in diabetes or congestive heart failure), the question to be asked then for further evaluation is, “Can we keep this from getting any worse, or developing complications?” The problems are not going to get better, but the healthcare team can generally intervene and prevent or minimize complications or decline. Another specific and measurable goal statement of care plan shall then be established. If the problem is not likely to improve, and deterioration is inevitable, then the last question according to Sox will be, “What can we do to provide optimal quality of life, comfort and dignity for this person?” This shows the continuity of the nursing process. The care planning process is never truly completed until the patient/resident is discharged from the hospital or passes away. The care plan needs to be adaptable and changeable, as the patient’s status changes. Periodic scheduled reevaluation must take place, with changes being made as needed. Unscheduled updates should also be made as condition warrants. When a problem has resolved, that problem can be completed. If the person has had a major change in a problem area that results in changes in goals and approaches, it may be easiest to resolve the problem and enter an entirely new problem, goal(s) and approaches, rather than making many changes to the existing problem. And so as the shift finishes, we will want to evaluate how our day went, whether we have completed everything we are responsible for, whether we have been organized, and what changes we should make for the next clinical day, and the cycle of providing nursing care continues so on and so forth. B. ‘Consider how well you communicate with patients/clients and detail what you do well and where there is room for improvement.’ This reflective piece intends to portray my thoughts, feelings and further explore and evaluate my ability to communicate with the patients in my department. It will also briefly explore the relatively new emphasized reflective practice and discuss the importance of good communication. In order to ensure thorough analysis/reflection I will be utilizing a well-known and comprehensive reflective model. Communication is a vital skill for nurses (Bulman 2004) and other healthcare professionals, it is often under estimated and underperformed in clinical practice. Good communication provides the patient with relevant information allowing informed consent and keeping patients informed also helps with compliance, health promotion and reduces their stress and anxiety (Alexander et al 2004). Communication is a vast subject area that encompasses both verbal and non-verbal communication, the paper will look at I communicate with patients and in particular keep them informed of their progress through the department. Many nurses claim to reflect on their clinical practice they give examples such as, discussions over coffee with colleagues or on the way home in the car. However, there is a difference between thinking about something and exploring it critically and learning from the experience (Ashby 2006). Reid (1993) defines it as a process of reviewing an experience of practice in order to describe, analyze and evaluate a situation, thus allowing learning to occur. Although reflective practice has long been a recognized method of learning, it is only recently that it has become increasingly common and encouraged by regulatory bodies (Atkins & Murphy 1994). There is wide ranging literature available (Paget 2001) and it is felt that reflective practice encourages nurses to maintain high standards of care by evaluating the procedures that worked and what could have been done differently and improved. There are a number of reflective models available to nurses and the chosen model depends on personal preference, I have chosen to utilize Gibbs (1988). Description Communication skill are an important skill of nursing staff within the department and in particular keeping patients and their relatives updated on their treatment and progress through the department. This includes explaining treatment plans, procedures, transfers, and lessen any anxieties that these may generate. Feelings Nursing in the emergency department can be very difficult and stressful often we are required to give patients and especially relatives’ bad news. For example, when meeting a patient for the first time it is important to be confident, empathetic and actively listen to ensure that all the reasons for admission can be identified and dealt with. Evaluation/Analysis Effectively communicating with the patients admitted to the department can sometimes be very difficult this is because they are predisposed to becoming stressed and anxious because they are often admitted under difficult circumstances. Communication sometimes becomes strained because the patient spends such a short period of time in the unit thus meaning that we cannot always forge strong relationships. The major barrier to effective communication is the fact that the department is obviously very busy and fast paced with patients being assessed, referred and diagnosed quickly. Therefore it can be difficult for us to be completely up to date with the treatment plan that has just been arranged. Patients are often too scared to ask us questions because we are busy. Non-verbal communication skills can sometimes be difficult for me to control, my face tends to say what I am thinking before I even open my mouth, this is something that I am very conscious of and try hard to prevent. However, I think that I am an effective communicator with patients and their relatives, when conversing with the patient I am aware of both verbal and non-verbal communication techniques and try to give explanations in terms that can easily be understood. I also try coming across as unhurried, keeping eye contact and sit at the same height as the person as much as I can. Additionally I attempt to use a quiet room where possible. Conclusion/Action Plan The unit and I are always looking for ways to improve our performance with patients. After exploring communication it is clear that we both need to make changes in order to improve the patient’s experience. For example I will pay more attention to my non-verbal communication skills as this a major component in the process. I will also try to include the patient’s relatives more in the assessment phase (where appropriate) as they can often provide important information on the patient’s problems and home lives. The department has introduced steps that ensure the medical staff seeks the nursing staff responsible for the patient in order to update them on the plan, thus allowing any questions to be easily dealt with. This also encourages us to update the patient more frequently. We also use multidisciplinary patient notes which also encourages good communication between professionals and hence patients. References Alexander, M. Fawcett, J. Runciman, P. (2000), Nursing Practice: Hospital and Home, 2nd. Ed, Churchill Livingstone, Edinburgh Anon, (2007), Components of Nursing Health History, Nursing Nurse [online], Available from: http://www.nursing-nurse.com/components-of-nursing-health-history-16/, Accessed 1st October 2008 AORN Sample Patient Records, Perioperative Nursing Data Set, 2nd. Ed, [online], Available from: http://www.aorn.org/docs_assets/55B250E0-9779-5C0D 1DDC8177C9B4C8EB/A33D80CE-17A4-49A8-86FF078CD71C1391/AORN_Sample_Patient_Records_Preoperative.pdf, Accessed 1st October 2008 Ashby, C. (2006), The benefits of reflective practice, Practice Nurse, 32(9) Atkins S. & Murphy K. (1994) Reflective practice, Nursing Standard, 8(39) BAI Clinical Forms and Procedures, (2002), Behavioural Analysis inc [online], Available from: http://www.behavior-analysis.org/Staff/Clinical%20Documents/staff_only_clinical_documents.htm, Accessed 1st October 2008 Bulman, C. Schuts, S. (2004) Reflective Practice in Nursing, 3rd ed. Blackwell Publishing, London, UK Clinical Nursing Assessments, (dateless) Department of Health and Senior Services, State of Missouri [online], Available from: http://www.dhss.mo.gov/HCBS/NurseAssessments.html, accessed 1st October 2008 Anon, (2007), Components of Nursing Health History, Nursing Nurse [online], Available from: http://www.nursing-nurse.com/components-of-nursing-health-history-16/, Accessed 1st October 2008 Daniels, R. (2004), Doenges and Morrorehouse’ Nursing Fundamentals: Caring and Decision making, Thomson Learning, New York Doenges, M. et al, (2002). Nursing Care Plans: Guidelines for individualizing Patient Care, 6th.ed, FA Davies Company, Philadelphia Gibbs, G. (1988), Learning by Doing: A Guide to Teaching and Learning methods., London: Further Education Unit Heath, H. (2005), Potter and Perry’s Foundations in Nursing Theory and Practice, Elsevier, Philadelphia Heiseman, D. (2008), Introduction to Assessment, Free-ED.net [online], Available from: http://www.free-ed.net/sweethaven/MedTech/NurseFund/default.asp?iNum=3&fraNum=060104, Accessed 1st October 2008 Kozier, B. et al, (2004), Fundamentals of Nursing: Concepts, Process and Practice, 7th.ed, Pearson Education, New Jersey Padget, T. (2001), Reflective practice and clinical outcomes: practitioners views on how reflective practice has influenced their clinical practice [online], available from: http://www.blackwell-synergy.com/doi/full/10.1046/j.1365-2702.2001.00482.x?cookieSet=1, Myers, E. (2003), Nurses Clinical Pocket Guide, FA Davies Company, Philadelphia Reid, B. (1993) But were doing it already! Exploring a response to the concept of reflective practice in order to improve its facilitation, Nurse Education Today 13, 305 309 Sox, H. What is a Care Plan? Care plans.com [online], Available from: http://www.careplans.com/default.asp, Accessed 1st October 2008 Read More