00:01
So, number one, guys,
why do we assess?
Well, there's a lot of reasons
why we do this.
00:06
First of all, we've got to see
the perceived needs of the client.
00:10
By doing this, we're going to identify
health concerns from the patient,
that could be things we see,
or maybe the patient reports,
for example.
00:17
And then we're going to identify
the primary priority problems,
that's really important.
00:24
So, this is going to give us a
database of information and data
to critically think through.
00:31
And that information
is going to give us a plan of care
of how we move forward
with treatment for a patient.
00:37
Then we can take all that data
and that plane of care.
00:40
And again, prioritize.
00:41
You're going to hear that a lot
in nursing school.
00:44
We got to prioritize
the patient's problems,
we're going to focus on
our patient's needs.
00:49
And then we're going to use
our critical thinking skills
to help us to get all this
information, synthesize it,
make sense of all this information,
and use it in a purposeful way
in how we treat our patient.
01:03
Now, let's talk about
that data in more detail.
01:06
Now, when we're talking about
those sources of data,
we've remember,
who is the primary source?
Don't forget your client.
01:13
This is where all that purposeful
information comes from.
01:17
This could be by of course,
the physical examination,
or head to toe assessment.
01:21
This is going to be the
best source of information.
01:24
This could be by
interviewing your client,
or even just observing
maybe their actions,
and how they respond
to treatment.
01:31
And of course, don't forget
about our objective data.
01:34
Like our vital signs,
or our diagnostic pieces.
01:37
Like labs, x-rays,
for example.
01:41
Now, the secondary source.
Again, it's a great source of data.
01:43
We use this as a little bit more
of a supporting information,
such as the healthcare team,
the medical records of the patient,
and also any scientific literature,
that's going to help back up,
how we're going to treat
our patient?
And of course,
don't forget,
there's family members
or significant others
that know their
patient really well.
02:02
They can also be
a great source of information.
02:05
Now, key thing
I want to tell you.
02:08
Family dynamics,
significant others can be,
there can be some
different dynamics going on there.
02:15
So make sure you check
with your client first,
to make sure you can
gather information
from the family or
the significant other.
02:25
Now, let's talk about data.
02:27
So this is really important
as a nursing student,
because there's a difference between
the type of data that we use.
02:34
we call it
subjective and objective data.
02:37
So when you're talking about
subjective data,
this is an important point
as a nursing student
to distinguish
between the two.
02:45
So subjective would be,
what you're told?
Versus objective,
meaning,
what you can actually
see or validate?
Here's a great example
I like to use personally, such as,
"Oh, my patient may tell me,
I'm nauseated."
Well, it's really
kind of hard to tell
if I look at someone,
just me as the nurse
to really see
that they're nauseated.
03:06
I can see objectively though,
if the patient vomits, right?
So that's a great example of
subjective versus objective data.
03:15
So here's a classic example.
03:17
Pain, for example.
03:19
Such as,
my patient may tell me,
"I'm having very bad pain
in my leg."
In a lot of times, again,
subjective data
is what the patient's
going to tell you.
03:29
Such as, again, "I'm having
very bad pain in my leg."
Well, the objective data
would be,
if the patient goes, and gets up,
and walks to the bathroom
and you see them grimacing,
or limping, when they're walking,
I can tangibly and objectively
see that as a nurse.
03:45
And that's what I would
document as my objective data.
03:49
Here's another example,
such as, "My client has a fever."
So I can't see that
my patient has a fever.
03:57
But objectively,
I can take a temperature
and the client's temperature
is 101.0 degrees Fahrenheit.
04:05
I can tangibly and objectively see
that my patient is running a fever.
04:10
So just know, again,
as a nursing student,
it's important that you distinguish
and as a nurse
subjective versus objective data,
because this is going to be
important for our documentation.
04:23
Now, let's talk about that process
and that data of assessment.
04:27
So first of all,
if you remember with assessment
for maybe our
primary or secondary source,
we're going to collect
all that data.
04:35
There's a lot of it.
04:37
So then, this is again,
where that
critical thinking comes in
that we've got a cluster
all that information.
04:44
And we'll start with
experience as a nurse,
identifying similarities between
certain disease processes
and certain patient complaints,
for example.
04:55
Then we're going to start
connecting more information
to form a complete
clinical picture.
05:00
And again, guys,
just know as a new nurse,
this takes a little time.
05:05
But with experience,
this gets much better.
05:08
So sometimes we're starting
to collect more information
such as laboratory results,
for example,
diagnostic reports.
05:16
Maybe a physician know
to pull in with what we assess,
to form a better clinical picture
for us as a nurse.
05:24
And lastly,
with assessment,
be sure you have supporting cues
before making an inference.
05:30
What do I mean by this?
So when we're
assessing our patient,
we need to not just make a judgement
based on no information, right?
We need to have supporting
assessment information,
supporting information
from the patient,
maybe client complaints,
before we make a judgement
about what the client needs.
05:50
Now, let's talk about
some assessment approaches
on how we gather information.
05:55
There's three very common types
we'll talk through.
05:58
So the first one
is the health history.
06:01
This is really important because
this gathers information.
06:04
And this lets us really understand
the patient's
current health problems
such as, maybe they have a
past medical history of diabetes,
or they've had surgery recently.
06:14
This is all important
for us to know,
as a nurse,
when we're taking care of them.
06:20
And of course, the head to toe
physical assessment.
06:22
Guys, we get so much information
from this.
06:26
This gives us a really baseline idea
of what our patient condition is.
06:30
It also helps us recognize
any abnormalities
that we may need to treat
or report to our physician.
06:37
And don't forget
focused assessment.
06:40
So this is looking closely
at a particular area of concern.
06:44
So maybe your patient's complaining
of gastrointestinal upset.
06:49
We're going to do more
of a focused assessment,
and ask more probing questions
due to our patient complaint here.
06:57
Now,
let's talk about
different methods
of information collection.
07:02
And first of all,
we're going to start of course,
with a client centered interview.
07:06
So this is really important,
because we're going to have
an organized conversation
with the client.
07:11
This is typically in the form of
a health history of a client,
for example.
07:15
Or also known as
the admission history assessment.
07:19
So when we start,
we're going to set the stage.
07:22
We're going to go ahead,
have our information ready
to ask our clients.
07:26
We're going to greet them,
let them know who we are,
and what we're doing.
07:31
It's also really important
to consider the environment.
07:34
And this is a lot of times things
that we don't consider as a nurse.
07:37
So it's important that,
if I go in to ask a patient
about a lot of
personal questions
about their health history,
if we can minimize distractions,
that's going to help a lot.
07:48
Also, it's a good idea to sit
and organize the agenda
about how you're going to gather
the information,
and also the clients concerns.
07:57
Now, we can go ahead,
and collect the assessment,
or that nursing health history.
08:01
And again, make sure that
we assure client confidentiality.
08:05
Sometimes clients
are a little bit concerned
about telling us
really intimate details
for the fact that they're worried
that that information
is going to go outside
in just you and the patient.
08:16
But this is important to assure
confidentiality with your patient.
08:21
Now, once we've gathered
our information successfully,
we can terminate the interview.
08:27
Now, let's talk
a little bit more about
when you are doing
that client interview.
08:31
How are you going to
interview them?
Let's talk about a
few tips about six
that are good things
to remember,
when you're interviewing a client.
08:39
One of those are
open-ended questions.
08:43
You'd be surprised when
you sit down with a patient
and just say,
Hey, here's an example.
08:48
"How are you feeling?"
Or you can get a lot of
information by just setting,
asking a simple
open-ended question
and then letting the patient talk.
08:58
It's also important to ask
clarifying questions, such as,
"Did I hear you say, etc.?"
So sometimes what that does
is let the patient know
that you're listening to them.
09:09
And also helps affirm
the information
that you're getting.
09:13
And don't forget
to validate the information.
09:16
The reason why this is important,
accurate information is critical on
making a plan of care for a patient.
09:24
So here's kind of a
small example of that
is maybe you get a report
that the patient's been
reporting pain in their leg.
09:30
So when I go
to see my patient,
I'm going to validate
that information.
09:35
I'm going to check
with my patient say,
"Hey, I heard that
you were having pain.
09:39
Can you tell me where?
Can you rate that from
a 0 to 10 scale?
Can you tell me about that pain?"
So we need to make sure that that
information we receive is accurate.
09:50
And again,
we've talked about this briefly.
09:53
It's important, especially
with those open-ended questions
like we were talking about.
09:58
Try not to interrupt your patient
too many times.
10:01
It's important that when
the patient's talking,
try to avoid interruptions.
10:05
And of course,
there are different
cultural, behavioral differences
that we need to be
respectful of.
10:11
So, if I go into my client's room,
some clients may be
really uncomfortable
with eye-to-eye contact.
10:18
Now, if I'm eye-to-eye contact
during the whole interview
that may intimidate your client.
10:23
So you need to be aware of these
cultural or behavioral differences.
10:28
And lastly, don't forget about
that data we talked about.
10:31
Differentiate
between subjective,
which is usually
what the patient tells you
and objective information
because again, this is going
to be important on how we treat,
and also
how we document.