Health Assess Ch. 04: Nursing Data Collection, Documentation & Analysis

validation; definition & 3 steps
verifies assessment data that you have gathered from the client.

1. determine which data require validation
2. implement techniques to validate
3. identify areas that require further assessment data

documentation
the act of recording the client assessment findings

1. understand purpose of documentation
2. learn which information to document
3. follow documentation guidelines for the given health care facility

when should you wear gloves when doing a physical assessment?
when coming in contact w/ body fluids
how many cm is ‘deep’ palpation?
2.5-5 cm
HOW do you validate your data?
(phys assess doesn’t match what patient told you
re-ask questions, clarify
re-test
check previous health records)

1. repeat assessment
2. clarify data w/ client
3. verify w/ another health care professional
4. compare findings

purposes of documentation
(make sure plan of care is appropriate
communicate to others)

1. chronolog source of data
2. prevents fragmentation/repetition
3. basis for screening
4. diagnose new problems
5. determine educational needs
6. eligibility for reimbursement
7. legal record of care

what do you document?
1. subj/biographic data
2. coldspa…
guidelines for documentation
1. don’t use ‘normal’… it’s meaningless. be objective
2. use phrases instead of sentences (not “upon palpation, blah blah blah” just write what you’re doing)
3. include client’s understanding (describe this by documenting their verbal responses to your teaching…)
4. record data findings, not how they were obtained
5. record what you see, NOT the medical diagnosis (two pts could both have bronchitis w/ very diff symptoms)
what is a feature of an open-ended document form?
provides for narrative description
Nurse Practice Act
standards of care, scope of duty
how do you cluster all the data?
* based on diagnosis or condition
* lifestyle risk factors (smoking & drinking)
what is evidence-based knowledge
info derived from research; make an educated decision based on that. don’t just do something because that’s the way it’s always been done.
what is evidence-based knowledge needed for nursing?
don’t want to use any practices that have been proven to not work!
critical thinking
is problem solving; much like the nursing process!
wellness diagnosis
pt considers self to be well/healthy; they’re just seeking education
how is nursing diagnosis different from medical diagnosis?
nursing diagnoses define the symptoms as opposed to just labeling
how do you avoid mistakes?
1. don’t jump to conclusions
2. practice! get the skill down, do it in the right order
what should a ‘with-it’ person be oriented to?
time
person
place
how do you assess mood/affect?
they response appropriately; don’t laugh if tell them they have cancer
assessing speech
appropriate wording?
can they articulate?
speech slurred?
does drawing a clock require higher cognitive function?
yes
when do you develop the ability to abstract?
early teens
stuporous
a pt who awakes to vigorous shake or painful stimulus but returns to unresponsive sleep
lethargic
open eyes, answer quesitons correctly, then fall back asleep
obtunded
opens eyes to loud voice, response slowly w/ confusion, seems unaware of envi
com
unresponsive to all stimuli; eyes stay closed
what does Glasgow coma scale assess?
do they open their eyes spontaneously?
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