2/1/14

Reviewing and Validating Findings

The nurse’s initial responsibility is to observe, collect, and record data without drawing conclusions or making judgments or assumptions. Self-awareness is a crucial factor in this interaction, because perceptions, judgments, and assumptions can easily color the assessment findings.

Validation is an ongoing process that occurs during the data-collection phase and upon its completion, when the data are reviewed and compared. The nurse should review the data to be sure that the recordings are factual, to identify errors of omission, and to compare the objective and subjective data for congruencies or inconsistencies that require additional investigation or a more focused assessment. Data that are grossly abnormal are rechecked, and any temporary factors that may affect the data are identified and noted. Validation is particularly important when the data are conflicting, when the data’s source may be unreliable, or when serious harm to the client could result from any inaccuracies. Validating the information reduces the possibility of making wrong inferences or conclusions that could result in inaccurate nursing diagnoses, incorrect outcomes, or inappropriate nursing actions. This can be done by sharing the assumptions with the individuals involved (e.g., client, significant other/family) and having them verify the accuracy of those conclusions. Sharing pertinent data with other healthcare professionals, such as the physician, dietician, or physical therapist, can aid in collaborative planning of care. Data given in confidence should not be shared with other individuals (unless withholding that information would hinder appropriate evaluation or care of the client).

Summary:
The assessment step of the nursing process emphasizes and should provide a holistic view of the client. The generalized assessment done during the overall data-gathering creates a profile of the client. A focused, or more detailed, assessment may be warranted given the client’s condition or emergent time constraints, or it may be done to obtain more information about a specific issue that needs expansion or clarification. Both types of assessments provide important
data that complement each other. A successfully completed assessment creates a picture of clients’ states of wellness, their response to health concerns or problems, and individual risk factors—this is the foundation for identifying appropriate nursing diagnoses, developing client outcomes, and choosing relevant interventions necessary for providing individualized care.
Read More

Discharge Plan Considerations

Projected length of stay (hours/days):________________________ 
Anticipated date of discharge:_______________________________
Date information obtained:________________________________ Source:________________________________________
Resources available: Persons:________ Financial:________ Community supports:________ Groups:________
Areas that may require alteration/assistance: Food preparation:_____ Shopping:_____ Transportation:_____ Ambulation:_____
Self-care (specify):________________________________ Socialization:________________________________
Medication/IV therapy:________________ Treatments:________________ Wound care:________________ Supplies:________________
Homemaker/maintenance(specify):________________________ 
Physical layout of home (specify):________________________
Anticipated changes in living situation after discharge:________________ 
Living facility other than home (specify):________________
Referrals (date/source/services): Social services:________________________ Rehabilitation:________________________
Dietary:________ Home care:________ Resp/O2:________ Equipment:________ Supplies:________ Other:________
Read More

Teaching/Learning Assessment Tool

Subjective (Reports)
Communication: Dominant language (specify):____________________________ 
Second language:____________________________
Literate (reading/writing):_________________________________________________________________________
Education level:______________ Learning disabilities (specify):______________ 
Cognitive limitations:________________
Culture/ethnicity:______________ Where born:______________ 
If immigrant, how long in this country:__________________
Health and illness beliefs/practices/customs:________________________________________________________
Which family member makes healthcare decisions/is spokesperson for client:_____________________________
_____________________________________________________________________________________________
Presence of Advance Directives:_______ Code status:_______ Durable Medical Power of Attorney:_______ Designee:______
Health goals:__________________________________________________________________________________
Current health problem:____________________________ 
Client understanding of problem:________________________________
Special healthcare concerns (e.g., impact of religious/cultural practices, healthcare decisions, family involvement):_______
Familial risk factors (indicate relationship):_______ Diabetes:_______ Thyroid (specify):_______ Tuberculosis:_______ Heart disease:_______
Stroke:___________________________________ High BP:___________________________________
Epilepsy/seizures:_______ Kidney disease:_______ Cancer:_______ Mental illness/depression:_______ Other:_______

Prescribed medications (list each separately):
Drug:_____________________ Dose:_____________________ Times (circle last dose):_____________________
Take regularly:_____________________ Purpose:_____________________ Side effects/problems:_____________________

Nonprescription drugs/frequency:
OTC drugs:______________ Vitamins:______________ Herbals:______________ Street drugs:______________
Alcohol (amount/frequency):______________ Tobacco:______________ Smokeless tobacco:______________
Admitting diagnosis per provider:____________________________________________________________________________________
Reason for hospitalization/visit per client:___________________________________________________________
History of current problem/concern:________________________________________________________________
Client expectations of this hospitalization/visit:_______________________________________________________
Will admission cause any lifestyle changes (describe):________________________________________________
Previous illnesses and/or hospitalizations/surgeries:__________________________________________________
Evidence of failure to improve:____________________________________________________________________

Last complete physical examination:______________________________________________________________
Read More

Sexuality (Component of Social Interaction) Assessment Tool

Subjective (Reports)

Sexually active:______________ Monogamous/committed relationship:______________ 
Use of condoms:______________
Birth control method:
_________________________________________________________________________________
Sexual concerns/difficulties: Recent change in frequency/interest: Pain/discomfort:__________________________

Objective: (Exhibits)
Comfort level with subject matter:___________________________________________________________________________

Female: Subjective (Reports)
Menstruation: Age at menarche:_______ Length of cycle:_______ Duration:_______ Number of pads/tampons used/day:_______ Last menstrual
period:_______ Bleeding between periods:_______ Menopausal:_______ Last period:_______ Hysterectomy (type/date):_______ Problems
with: Hot flashes:_______ Night sweats:_______ Vaginal lubrication:_______ Vaginal discharge:_______
Gynecological/breast surgery (type and date):____________________________________________________
______________________________________
Infertility concerns:___________________________________ Type of therapy:_________________________
Pregnant now:__________________ Para:__________________ Gravida:__________________ 
Due date:__________________
Practices breast self-examination:______________ Last mammogram:______________ 
Last Pap smear/results:______________
Hormonal therapy:______________ Supplemental calcium:______________ 
Other medications/herbals:______________

Objective (Exhibits)
Breast examination:__________________________________________________________________________________
Genitalia:__________________ Warts/lesions:__________________ 
Vaginal bleeding/discharge:__________________
Test results: __________________Pap:__________________ Mammogram: STD:__________________

Male: Subjective (Reports)
Penis: Circumcised:____________________ Lesions/discharge:____________________ Vasectomy:_____________________
Prostate disorder/voiding difficulties:_______________________________________________________________________
Practice self-examination: Breast:____________________________ Testicles:____________________________
Last proctoscopic/prostate examination:____________________________ 
Last PSA:____________________________
Medications/herbals:_________________________________________________________________________________________________________________________________________________________________________

Objective (Exhibits)
Genitalia: Penis:_______ Warts/lesions:_______ Bleeding/discharge:_______ Testicles (e.g., descended, lumps):_______
Prostate:_____________________________________________________________________________________________________
Breast examination:____________________________________________________________________________
_________________________________________
Test results:_______________________________ STD:_______________________________ PSA:_______________________________
Read More

Safety Assessment Tool

Subjective (Reports)
Allergies/sensitivity (medications, foods, environment, latex):___________________________________________
__________________________________________________
Type of reaction:_______________________________________________________________________________
Blood transfusion/number:______________ Date:______________ Reaction (describe):______________

Exposure to infectious diseases (e.g., measles, influenza, pink eye):
_____________________________________________________________________________________________
Exposure to pollution, toxins, poisons/pesticides, radiation (describe reactions):
_____________________________________________________________________________________________
Geographic areas lived in/recent travel:
_____________________________________________________________________________________________
Immunization history/date: Tetanus:_______ MMR:_______ Polio:_______ Hepatitis:_______ Pneumonia:_______ Influenza:_______ HPV:_______
Altered/suppressed immune system (list cause):
_____________________________________________________________________________________________
History of sexually transmitted disease (date/type):________________________________ Testing:_________________________________
High-risk behaviors (specify):
_____________________________________________________________________________________________
Uses seat belt regularly:______________ Uses bike helmet:______________ Other safety devices:______________
Work place safety/health issues (describe):_______ Occupation:_______ Currently working:_______ 
Rate working conditions (e.g.,safety, noise, heating, water, ventilation):
_____________________________________________________________________________________________
History of accidental injuries:____________________________ Fractures/dislocations:____________________________
Arthritis/unstable joints:__________________________________________ 
Back problems:__________________________________________
Skin problems (e.g., rashes, lesions, moles, breast lumps, enlarged nodes)/describe:_______________________
_________________________________________
Delayed healing (describe):______________________________________________________________________
_________________________________________
Cognitive limitations (e.g., disorientation, confusion):__________________________________________________
___________________________________________
Sensory limitations (e.g., impaired vision/hearing, detecting heat/cold, taste, smell, touch):__________________
___________________________________________
Prosthesis:____________________________ Ambulatory devices:____________________________
Violence (episodes or tendencies):________________________________________________________________
____________________________

Objective (Exhibits)
Body temperature/method (e.g., oral, rectal, tympanic):_______________________________________________
Skin integrity (mark location on diagram):_______ Scars:_______ Rashes:_______ Lacerations:_______ Ulcerations:_______ Bruises:_______
Blisters:______________ Drainage:______________ Burns (degree/% of body surface):______________
Safety Assessment Tool 
Musculoskeletal: General strength:________ Muscle tone:_________ Gait:________ 
ROM:______ Paresthesia/paralysis:_____
Results of testing (e.g., cultures, immune function, TB, hepatitis):___________________________
_________________________________________________________________________________
Read More

Respiration Assessment Tool

Subjective (Reports)
Dyspnea/related to: _______________ Precipitating factors:_______________ 
Relieving factors:_______________
Airway clearance (e.g., spontaneous/device):________________________________________________________
Cough (e.g., hard, persistent, croupy):_______________ Sputum color/character:_______________ Requires suctioning:_______________
History of/date: Bronchitis:_____ Emphysema:_____ Tuberculosis:_____ Recurrent pneumonia:_____ 
Exposure to noxious fumes/allergens, infectious agents/diseases, poisons:
_____________________________________________________________________________________________
Smoker:__________ packs/day:__________ # of pack years:__________ Cigar use:__________ Smokeless:__________
Use of respiratory aids:_________________________ Oxygen (type & frequency):_________________________
Medications/herbals:______________________________________________________________________________________________________________

Objective (Exhibits)
Respirations (spontaneous/assisted):_____ Rate:_____ Depth:_____ Chest excursion (e.g., equal/symmetrical):_____ 
Use of accessory muscles:_______________ Nasal flaring:_______________ Fremitus:_______________
Breath sounds (describe):_________________________ Egophony:_________________________
Skin/mucous membrane color (e.g., pale, cyanotic):____________________ 
Clubbing of fingers:______________________
Sputum characteristics:_________________________________________________________________________
Mentation (e.g., calm, anxious, restless):_______________________________________________________________________
Pulse oximetry:_____________________________________________________________________________________
Read More

Pain/Discomfort Assessment Tool

Subjective (Reports)

Primary focus:Location:______________________ Intensity (use pain scale/pictures):______________________
Quality (e.g., stabbing, aching, burning):____________________________ Radiation:____________________________
Frequency:_______________________________________________ Duration:_________________________________________________
Precipitating/aggravating factors:__________________________________________________________________
How relieved: OTC/prescription:____________________________ Nonpharmaceuticals/therapies:___________________________
Associated symptoms (e.g., nausea, sleep problems, photosensitivity):__________________________________
Effect on daily activities:______________ Relationships:____________ Job:____________ 
Enjoyment of life:____________
Additional pain focus/describe:________________________________________________________________________________
Cultural expectations regarding pain perception and expression:
_____________________________________________________________________________________________

Objective (Exhibits)
Facial grimacing:_________ Guarding affected area:_________  Posturing:_________  Behaviors:_________  Narrowed focus:_________ 
Emotional response (e.g., crying, withdrawal, anger):
_________________________________________________________________________________________
Vital sign changes (acute pain): BP:__________________ 
Pulse:__________________ 
Respirations:__________________
Read More