Health care agencies may choose from a variety of assess- ment forms for documentation depending on the type of agency, the population served by the facility, and the primary reasons for documentation. For example, clients seeking health care in a clinic or prescribing practitioner’s office might be asked to complete a brief self-questionnaire, while a client admitted to an acute care facility for labor and delivery might be asked to provide only information directly related to pregnancy and child care needs. Four types of documentation
formats include open-ended, checklist, combination, and specialty. See Figure 6-2 on page 99 for an example of a form used in occupational nursing.
Open-Ended Formats
The open-ended format for documentation allows the nurse to write a narrative description of observations (see Figure 6-3 on page 100). This format is more time-consuming for the nurse but allows flexibility in recording findings.
Checklist Formats
Formats that include checklists facilitate documentation by summarizing findings in an abbreviated form (see Figure 6-4 on pages 101–104). They also provide more consistency in the recording of information and reduce the likelihood of omitting relevant information. However, checklists may dis- courage nurses from obtaining elaboration about observa- tions from clients that require further explanation. For example, if a checklist indicates that mobility is impaired, fur- ther explanation is required in order to determine the extent of the impairment and thus plan the necessary interventions.
Combination Formats
Combination formats often allow the convenience of a checklist together with space to document a complete nar- rative description of any significant or abnormal findings (see Figure 6-5 on page 105). Some agencies provide cues on the form to alert personnel when further information is needed. This format provides for some consistency in re- cording data while allowing flexibility for documenting spe- cific information.
Specialty Formats
Specialty areas such as outpatient surgery, labor and delivery, and psychiatric facilities may use abbreviated formats focused directly on assessment needs for the particular service pro- vided. In addition, specialty assessment forms may be included together with comprehensive assessment forms for clients at particular risk for various conditions (e.g., falls, impaired skin integrity).
Documentation of assessment data is essential as a means of communication among health care team members to ensure accurate problem identification, determination of appropriate client outcomes, and continuity of care.
The Minimum Data Set
The Minimum Data Set (MDS) was developed by the Cen- ters for Medicare and Medicaid Services (CMS) to promote the development of a comprehensive care plan for every resi- dent of Medicare- or Medicaid-certified nursing homes. As such, the MDS is a standardized assessment instrument used in all long-term care facilities that are funded by CMS. The MDS is a comprehensive assessment tool designed to collect data about client needs.
The following is an example of an occupational health history used in industrial settings.
Current Job:
A. What is your current job title? _____________________________________________________
B. How long have you had this job?___________________________________________________
C. What are specific tasks you perform on the job?_______________________________________
________________________________________________________________________________
________________________________________________________________________________
D. Are you exposed to any of the following on your present job?
___Chemicals ___Infectious agents ___Stress ___Dust ___Loud noise ___Vapors, gases ___Extreme ___Radiation ___Vibrations temperature
changes
E. Do you think you have any work-related health problems?
If so, describe:__________________________________________________________________
F. How would you describe your satisfaction with your job?
___Very satisfied ___Satisfied ___Somewhat satisfied ___Dissatisfied ___Very Dissatisfied G. Have there been any recent changes in your job or work hours?
H. Do you use protective equipment or clothing on your job?
If so, list items used:_____________________________________________________________
Past Work Experience:
Please provide the following information, starting with your first job:
Job Title Dates Held Brief Description of Job Exposures Injuries/Illnesses l.
l l.
Application: Assessment in the Industrial Clinic
FIGURE6-2Application: Assessment in the Industrial ClinicDELMAR/CENGAGE LEARNING
Demographic Data: Date of birth___________________ Gender___________________ Marital status____________________
Reason for Seeking Health Care:_________________________________________________________________________________
_____________________________________________________________________________________________________________
Perception of Health Status:_____________________________________________________________________________________
_____________________________________________________________________________________________________________
Previous Illness/Hospitalization/Surgeries:_________________________________________________________________________
_____________________________________________________________________________________________________________
Client/Family Medical History:
Addiction (drugs/alcohol)__________ Diabetes____________________
Arthritis_______________________ Heart disease________________
Cancer________________________ Hypertension________________
Chronic lung disease_____________ Kidney disease_______________
Mental disorders_____________________
Sickle cell anemia____________________
Stroke_____________________________
Other______________________________
Immunizations/Exposure to Communicable Disease:________________________________________________________________
_____________________________________________________________________________________________________________
Allergies:_____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Home Medications:_____________________________________________________________________________________________
_____________________________________________________________________________________________________________
Developmental Level:___________________________________________________________________________________________
_____________________________________________________________________________________________________________
Psychosocial History:
Alcohol use: ___________________________________________________________________________________________________
Tobacco use:___________________________________________________________________________________________________
Drug use: _____________________________________________________________________________________________________
Caffeine intake:_________________________________________________________________________________________________
Self-perception/Self-concept:____________________________________________________________________________________
_____________________________________________________________________________________________________________
Sociocultural History:
Family structure________________________________________________________________________________________________
Role in family__________________________________________________________________________________________________
Cultural/ethnic group____________________________________________________________________________________________
Occupation/work role____________________________________________________________________________________________
Relationships with others_________________________________________________________________________________________
Activities of Daily Living:
Nutrition: Type of diet_________________________________________ Usual weight_________________________________
Eating patterns_________________________________________________________________________________________________
Types of snacks________________________________________________________________________________________________
Food likes/dislikes_______________________________________________________________________________________________
Fluid intake: Type_____________________________________________
Elimination (usual patterns): Urinary_____________________________ Bowel_____________________________________
Sleep/Rest:
Usual sleep patterns_____________________________________________________________________________________________
Relaxation techniques/patterns_____________________________________________________________________________________
Activity/Exercise:
Usual exercise patterns___________________________________________________________________________________________
Ability to perform self-care activities_________________________________________________________________________________
Review of Systems:
Respiratory___________________________________________________________________________________________________
Circulatory____________________________________________________________________________________________________
Integumentary_________________________________________________________________________________________________
Musculoskeletal________________________________________________________________________________________________
Neurosensory_________________________________________________________________________________________________
Reproductive/Sexuality__________________________________________________________________________________________
Health Maintenance Activities:
Usual source of health care_______________________________________________________________________________________
Date of last exam (physical, dental, eye)_____________________________________________________________________________
Other health maintenance activities_________________________________________________________________________________
Amount____________________________________
HEALTH HISTORY
Name________________________________ Date__________________ Time_______________
FIGURE6-3Sample Assessment Form: Open-EndedDELMAR/CENGAGE LEARNING
FIGURE6-4Sample Assessment Form: ChecklistREPRINTED WITH PERMISSION FROM NORTH OAKS MEDICAL CENTER, HAMMOND, LA
FIGURE6-4Continued
FIGURE6-4Continued
FIGURE6-4Continued
Date_______ Time______ Baseline Data: Ht____Wt____T____P____R____BP____
Admitted from: Home____ER____Other____ Mode of Transport: Stretcher____W/C____Amb____
Allergies_____________________________ Home Meds: ____________________ ___________________
____________________ ___________________
Mental Status Comment
Alert/Oriented Yes No __________
Confused Yes No __________
Anxious Yes No __________
Comatose Yes No __________
Combative Yes No __________
Other______________________________________________
Communication Comment
Speaks English Yes No __________
Aphasic Yes No __________
Speech Impediment Yes No __________
Sensory Comment
Hearing Impaired Yes No __________
Visually Impaired Yes No __________
Amputation Yes No __________
Hemiplegia Yes No __________
Paraplegia Yes No __________
Diet/Nutrition
Diet at Home________________________________________
Likes/Dislikes_______________________________________
Appetite___________________________________________
Skin Location
Warm/Dry Yes No __________
Abrasions/Bruises Yes No __________
Laceration/Scar Yes No __________
Reddened Areas Yes No __________
Decubitus Ulcers Yes No __________
Burns Yes No __________
Rash/Scaling Yes No __________
Diaphoretic Yes No __________
Other______________________________________________
Color: Pale Normal Cyanotic Treatments in Progress:______________________________
___________________________________________________
___________________________________________________
ADMISSION ASSESSMENT
Elimination Comment
GI: Constipation Yes No __________
Frequency Yes No __________
Laxatives Yes No __________
Other__________________________________________
GU: Frequency Yes No __________
Burning Yes No __________
Incontinent Yes No __________
Other__________________________________________
Sleeping
Unable to fall asleep Yes No __________
Awakens frequently Yes No __________
Sleep meds Yes No __________
Naps Yes No __________
ADL
Assistance needed for:
Ambulation Yes No __________
Eating Yes No __________
Bathing Yes No __________
Dressing Yes No __________
Eliminating Yes No __________
Turning Yes No __________
Other______________________________________________
Denture Yes No __________
Glasses Yes No __________
Contact Lenses Yes No __________
Personal Habits:
Tobacco use Yes No __________
(quantity)
Alcohol use Yes No __________
(quantity)
Chief Complaint:____________________________________
___________________________________________________
___________________________________________________
Other Assessment Data:______________________________
___________________________________________________
___________________________________________________
____________________ ___________________
Comment
Comment
FIGURE6-5Sample Assessment Form: CombinationDELMAR/CENGAGE LEARNING
KEY CONCEPTS
• Assessment includes collection, verification, organi- zation, interpretation, and documentation of data.
• The nurse uses the process of assessment to estab- lish a database about the client, to form an interper- sonal relationship with the client, and to provide the client with an opportunity to discuss health care concerns.
• Assessment can be comprehensive, focused, or ongoing, depending on the health care setting and needs of the client.
• The two types of data collected during the assess- ment process are subjective (data from the client’s point of view) and objective (observable and meas- urable data that are obtained through both the phys- ical examination and laboratory and diagnostic tests).
• Although a variety of sources should be used in data collection, the client is the primary source of infor- mation.
• Assessment models such as Gordon’s functional health patterns, NANDA’s human response pat- terns, Orem’s theory of self-care model, Roy’s adap- tation model, the body systems model, and
Maslow’s hierarchy of needs model ensure compre- hensive data collection and organization.
• Data are collected through the interview, health his- tory, symptom analysis, physical examination, and laboratory and diagnostic tests.
• The three stages of assessment interview are the introduction, working, and closure phases.
• A comprehensive health history is useful in deter- mining the client’s functional health patterns, responses to changes in health status, and alterations in lifestyle.
• The elements of the health history are demographic information; reason for seeking health care; percep- tion of health status; previous illnesses, hospitaliza- tions, and surgeries; client and family medical history; immunizations and exposure to communica- ble disease; allergies; current medications; develop- mental level; psychosocial history; sociocultural history; activities of daily living; and review of sys- tems.
• The purposes of the physical examination are to gather baseline data, confirm data obtained in the interview and health history, and evaluate progress toward established goals.
• The physical examination includes the techniques of inspection, palpation, percussion, and auscultation.
• Accurate and complete documentation of assess- ment findings is essential for communication to other health care team members.
• Data may be recorded on a variety of tools, such as open-ended, checklist, combination, and specialty formats.
REVIEW QUESTIONS
1. Which of the following nursing responses is an example of an open-ended statement?
a. ‘‘Are you feeling better?’’
b. ‘‘Do you have any pain now?’’
c. ‘‘Tell me about your health.’’
d. ‘‘Tell me how many children you have.’’
2. The process of assessment includes which of the following activities? Select all that apply.
a. Collecting b. Documenting c. Interpreting d. Organizing e. Planning f. Verifying
3. A 72-year-old client comes to the emergency department for treatment of difficult, painful urina- tion. What type of assessment is most appropriate for this client?
a. Comprehensive b. Focused c. Ongoing
d. Subjective
4. The nurse is performing an admission assessment.
Which of the following are examples of objective data? Select all that apply.
a. 10 cc of emesis in basin b. Cool, clammy skin
c. Client says, ‘‘My feet are swollen.’’
d. Complaint of nausea by client e. Oral temperature 103°F f. Rapid, thready pulse
5. When performing an assessment, which of the fol- lowing would the nurse use as a primary source of data?
a. All health care personnel b. Client
c. Client family and/or friends d. Client medical records
6. Which of the following statements accurately describes the review of systems (ROS)?
a. It is performed by the nurse at the earliest possi- ble time.
b. It is the client’s statement about perceived health status.
c. ROS should be performed only by advanced nurse practitioners.
d. The nurse does a head-to-toe physical examina- tion of the client.
7. A newly admitted client states that she has a severe headache. What is the nurse’s first action?
a. Administer pain medication as ordered in the cli- ent’s medical record.
b. Check the client’s vital signs.
c. Have the client sign consent forms for treatment and diagnostic procedures.
d. Orient the client to the unit and explain safety guidelines.
online companion
Visit the DeLaune and Ladner online companion resource atwww.delmar.cengage.comfor additional content and study aids. Click on Online Companions, then select the Nursing discipline.
—JOHNDEWEY
CHAPTER 7
Nursing Diagnosis
COMPETENCIES
1. Describe nursing diagnosis as a critical step in clinical judgment.
2. Explain the purposes of nursing diagnoses.
3. List the types of nursing diagnoses and the components of each type.
4. Explore characteristics of the nursing diagnosis taxonomy.
5. Describe the process of developing a nursing diagnosis.
6. Identify common errors in developing a nursing diagnosis.
7. Discuss limitations of nursing diagnoses.
8. Explore barriers that can affect the use of a nursing diagnosis.
9. Describe strategies to overcome limitations of and barriers to using nursing diagnoses.
10. Describe how a nursing diagnosis enables the delivery of holistic, comprehensive nursing care.
11. Explain how a nursing diagnosis enhances accountability and empowerment in the nursing profession.
109
T
henursing diagnosisis the second step in the nursing process and includes clinical judgments made about wellness states, illness states and syndromes, and the readi- ness to enhance current states of wellness experienced by individuals, families, and aggregate populations (commun- ities). Diagnosing is based on a critical analysis of the assess- ment data. The purpose of a nursing diagnosis is to effectively communicate client needs among members of the health care team. Society tends to interpret nursing through the use of nursing language. When a nursing diagnosis is a part of the client’s plan of care, the nurse is able to communi- cate the client’s needs to other professionals involved in that care. These needs encompass physiologic, role function, self- concept, interdependence, and spiritual dimensions. To determine individualized therapeutic nursing interventions, the nurse must develop appropriate nursing diagnoses that are based on organized assessment data.This chapter describes the nature of a nursing diagnosis, the purpose and types of nursing diagnoses, and the compo- nents of a nursing diagnostic statement. Development of nursing diagnoses and methods for avoiding diagnostic errors in the formulation of nursing diagnoses are also presented.
Strategies for overcoming barriers to the use of nursing diag- noses are discussed.