University of Texas NURS 3320 Exam 1 Review

EXAM 1 REVIEW        NURS 3320

CHAP 1: NURSE’S ROLES IN ASSESSMENT: COLLECTING AND ANALYZING DATAS

A.            INTRODUCTION TO HEALTH ASSESSMENT IN NURSING

-Nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human responses and advocacy in the care of individuals, families, communities, and populations.”

-Emphasis is placed on “diagnosis and treatment of human responses” based on “accurate client assessments,” including how effective nursing interventions are “to promote health and prevent illness and injury.”

-  “The registered nurse collects comprehensive data pertinent to the patient’s health or situation”

To accomplish this pertinent and comprehensive data collection, the nurse:

•                                      Collects data in a systematic and ongoing process

•                        Involves the patient, family, other health care providers, and environment, as appropriate, in holistic data collection

•                        Prioritizes data collection activities based on the patient’s immediate condition, or anticipated needs of the patient or situation

•                        Uses appropriate evidence-based assessment techniques and instruments in collecting pertinent data

•                                      Uses analytical models and problem-solving tools

•                        Synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances

•                                      Documents relevant data in a retrievable format (ANA, 2010, p. 21)

Standard 2 states, “The registered nurse analyzes the assessment data to determine the diagnoses or issues. To accomplish this, the registered nurse:

•                                      Derives the diagnosis or issues based on assessment data

•                        Validates the diagnoses or issues with the client, family, and other health care providers when possible and appropriate

•                        Documents diagnoses or issues in a manner that facilitates the determination of the expected outcomes and plan

B.            NURSE’S ROLES IN HEALTH ASSESSMENT

Current focus on managed care and internal case management has had a dramatic impact on the assessment role of the nurse

Current focus on managed care and internal case management has had a dramatic impact on the assessment role of the nurse.

•                   The acute care nurse performs a focused assessment, and then incorporates assessment

findings with a multidisciplinary team to develop a comprehensive plan of care

•                   Critical care outreach nurses need enhanced assessment skills to safely assess critically ill clients who are outside the structured intensive care environment

•                   Ambulatory care nurses assess and screen clients to determine the need for physician referrals.

•                   Home health nurses make independent nursing diagnoses and referrals for collaborative problems as needed.

•                   Public health nurses assess the needs of communities, school nurses monitor the growth and health of children, and hospice nurses assess the needs of the terminally ill clients and their families

In all settings, the nurse increasingly documents and retrieves assessment data through sophisticated computerized information systems (Cowen & Moorhead, 2014). Nursing health assessment courses with informatics content are becoming the norm in baccalaureate programs.