Assessment - First Step in the Nursing Process

It is systematic and continuous collection, validation and communication of client data as compared to what is standard/norm. It includes the clients perceived needs, health problems, related experiences, health practices, values and lifestyles.

Purpose
To establish a data base (all the information about the client): nursing health history physical assessment the physicians history & physical examination results of laboratory & diagnostic tests material from other health personnel

FOUR Types of Assessment

1. Initial assessment assessment performed within a specified time on admission o Ex: nursing admission assessment 2. Problem-focused assessment use to determine status of a specific problem identified in an earlier assessment o Ex: problem on urination-assess on fluid intake & urine output hourly 3. Emergency assessment rapid assessment done during any physiologic/physiologic crisis of the client to identify life threatening problems. o Ex: assessment of a clients airway, breathing status & circulation after a cardiac arrest. 4. Time-lapsed assessment reassessment of clients functional health pattern done several months after initial assessment to compare the clients current status to baseline data previously obtained.

Activities
1. 2. 3. 4. 5. Collection of data Validation of data Organization of data Analyzing of data Recording/documentation of data

Assessment
Observation of the patient + Interview of patient, family & SO + examination of the patient + Review of medical record

Collection of data
gathering of information about the client includes physical, psychological, emotion, socio-cultural, spiritual factors that may affect clients health status includes past health history of client (allergies, past surgeries, chronic diseases, use of folk healing methods) includes current/present problems of client (pain, nausea, sleep pattern, religious practices, meds or treatment the client is taking now)

Types of Data 1. Subjective data o also referred to as Symptom/Covert data o Information from the clients point of view or are described by the person experiencing it. o Information supplied by family members, significant others; other health professionals are considered subjective data. o Example: pain, dizziness, ringing of ears/Tinnitus 2. Objective data o also referred to as Sign/Overt data o Those that can be detected observed or measured/tested using accepted standard or norm. o Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin Methods of Data Collection 1. Interview o A planned, purposeful conversation/communication with the client to get information, identify problems, evaluate change, to teach, or to provide support or counseling. o it is used while taking the nursing history of a client 2. Observation o Use to gather data by using the 5 senses and instruments. 3. Examination o Systematic data collection to detect health problems using unit of measurements, physical examination techniques (IPPA), interpretation of laboratory results. o should be conducted systematically: 1. Cephalocaudal approach head-to-toe assessment 2. Body System approach examine all the body system 3. Review of System approach examine only particular area affected Source of data 1. Primary source data directly gathered from the client using interview and physical examination. 2. Secondary source data gathered from clients family members, significant others, clients medical records/chart, other members of health team, and related care literature/journals.

In the Assessment Phase, obtain a Nursing Health History - a structured interview designed to collect specific data and to obtain a detailed health record of a client.

Components of a Nursing Health History: o o o o o o o o o o Biographic data name, address, age, sex, martial status, occupation, religion. Reason for visit/Chief complaint primary reason why client seek consultation or hospitalization. History of present Illness includes: usual health status, chronological story, family history, disability assessment. Past Health History includes all previous immunizations, experiences with illness. Family History reveals risk factors for certain disease diseases (Diabetes, hypertension, cancer, mental illness). Review of systems review of all health problems by body systems Lifestyle include personal habits, diets, sleep or rest patterns, activities of daily living, recreation or hobbies. Social data include family relationships, ethnic and educational background, economic status, home and neighborhood conditions. Psychological data information about the clients emotional state. Pattern of health care includes all health care resources: hospitals, clinics, health centers, family doctors.

Validation of Data
The act of double-checking or verifying data to confirm that it is accurate and complete.

Purposes of data validation 1. 2. 3. 4. 5. Cues Subjective or objective data observed by the nurse; it is what the client says, or what the nurse can see, hear, feel, smell or measure. ensure that data collection is complete ensure that objective and subjective data agree obtain additional data that may have been overlooked avoid jumping to conclusion differentiate cues and inferences

Inferences The nurse interpretation or conclusion based on the cues. Example: o Red swollen wound = infected wound o Dry skin = dehydrated

Organization of Data
Uses a written or computerized format that organizes assessment data systematically. 1. Maslows basic needs 2. Body System Model 3. Gordons Functional Health Patterns: Gordons Functional Health Patterns 1. Health perception-health management pattern. 2. Nutritional-metabolic pattern 3. Elimination pattern 4. Activity-exercise pattern 5. Sleep-rest pattern 6. Cognitive-perceptual pattern 7. Self-perception-concept pattern 8. Role-relationship pattern 9. Sexuality-reproductive pattern 10. Coping-stress tolerance pattern 11. Value-belief pattern

Analyze data
Compare data against standard and identify significant cues. Standard/norm are generally accepted measurements, model, pattern: o Ex: Normal vital signs, standard Weight and Height, normal laboratory/diagnostic values, normal growth and development pattern

Communicate/Record/Document Data
nurse records all data collected about the clients health status data are recorded in a factual manner not as interpreted by the nurse Record subjective data in clients word; restating in other words what client says might change its original meaning.

Assist Patient from the Bed to Chair or Wheelchair

I. Purpose
1. To strengthen the patient gradually. 2. To provide a change in position. (In wheelchair to take her around for a change)

II. Equipment
Chair or wheelchair Patients robe and slippers Pillows Blanket, sheet or draw sheet

III. Procedure
1. See that the chair or wheelchair is in good condition. 2. Place the chair conveniently at night angles to the bedback of chair parallel to the foot of the bed and facing the head of bed. 3. Place pillow on the seat of the chair. If using wheelchair, line it with a blanket or sheet and arrange pillows on the seat and against the back. Put the foot rest up and lock the wheels. 4. Take the patients pulse 5. Assist the patient to a sitting position on bed, i.e., put one arm under the head and shoulders and the other arm under her knees and pivot her to a sitting position with the legs hanging over the side of the bed. 6. Watch the patient for a minute to defect any change in his color, pulse and respiratory rate. 7. Put on patients robe and slippers. Place the foot stool under the patients feet. 8. Stand directly in front of the patient and with a hand under each axilla, assist him to stand, step down and turn around, with his back to the chair. Let patient flex his knees and lower body to seat him to the chair. Anchor chair with foot or have someone hold it on. (Or let patient place his arm over your shoulders while you put your arm around his waist. Turn patient around with his back to the chair and seat him gently). Help him get comfortable in the chair. 9. Adjust the pillows and wrap blanket over patients lap. If in a wheelchair adjust the foot rests. 10. Observe frequently for changes in color and pulse rate, dizziness or sign of fatigue. 11. To put him back to bed, assist to stand, help to turn and stand on stool and back to bed. Support patient while he sits on the side of bed. Remove robe and slippers. Pivot to a sitting position in bed, supporting her head and shoulders with one arm and her knees with the other arm, and lower slowly to bed in lying position. 12. Draw up bedding. Take pulse after.

BACK CARE
After bathing and drying the back, it should be massaged or rubbed thoroughly.

I. Purpose
1. To stimulate the circulation and give general relief. 2. To prevent bedsore 3. To give comfort to the patient.

II. Equipment
Alcohol 25% Talcum powder Bath towel

III. Procedure
1. Help the patient to turn on his abdomen or on his side with his back toward the nurse and his body near the edge of the bed so that he is as near the operator as possible. If the supine position is used and the patient is a woman, pillow under the abdomen removes pressure from the breasts and favor relaxation. 2. Raise the camisa and gown. 3. Apply to back rubbing lotion or talcum powder to reduce friction. In rubbing the back use firm long strokes and kneading motions. The amount of pressure to exert depends upon the patients condition. Begun from neck and shoulders then proceed over the entire back. 4. Massage with both hands working with a strong stroke. In upward than in downward motions. Give particular attention to pressure areas in rubbing (Alcohol 25%) to 50% is generally used for its refreshing effect, but rubbing lotion may be used.) 5. Powder again the area at the completion of the rubbing process which should consume from 3-5 minutes. 6. Turn patient on his back and put on camisa or gown. 7. Fix and make patient comfortable.

Movements Used
1. Effleurage (strokingis a long sweeping movement with palm of hand conforming to the contour of the surface treated, over small surface (on the neck) the thumb and fingers are used. Strokes should be slow, rhythmical and gentle with pressure constant and in the direction of venous stream. 2. Kneadingperformed with the ulnar side palm resting on the surface and the fingers, and thumble grasping the skin and subcutaneous tissues which move with the hand of the operator. 3. Frictionis performed with the whole palmar surface of the hand or fingers and thumbs over limited areas. This movement is a circular from of kneading with pressure against the underlying part of tissue which cannot be grasped.

Blood transfusion therapy involves transfusing whole blood or blood components

(specific portion or fraction of blood lacking in patient). One unit of whole blood consists of 450 mL of blood collected into 60 to 70 mL of preservative or anticoagulant. Whole blood stored for more than 6 hours does not provide therapeutic platelet transfusion, nor does it contain therapeutic amounts of labile coagulation factors (factors V and VIII).

Blood components include:

1. Packed RBCs (100% of erythrocyte, 100% of leukocytes, and 20% of plasma originally present in one unit of whole blood), indicated to increase the oxygencarrying capacity of blood with minimal expansion of blood. 2. Leukocyte-poor packed RBCs, indicated for patients who have experience previous febrile no hemolytic reactions. 3. Platelets, either HLA (human leukocyte antigen) matched or unmatched. 4. Granulocytes ( basophils, eosinophils, and neutrophils ) 5. Fresh frozen plasma, containing all coagulation factors, including factors V and VIII (the labile factors). 6. Single donor plasma, containing all stable coagulation factors but reduced levels of factors V and VIII; the preferred product for reversal of Coumadin-induced anticoagulation. 7. Albumin, a plasma protein. 8. Cryoprecipitate, a plasma derivative rich in factor VIII, fibrinogen, factor XIII, and fibronectin. 9. Factor IX concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma. 10. Factor VIII concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma. 11. Prothrombin complex, containing prothrombin and factors VII, IX, X, and some factor XI.

Advantages of blood component therapy

1. Avoids the risk of sensitizing the patients to other blood components. 2. Provides optimal therapeutic benefit while reducing risk of volume overload. 3. Increases availability of needed blood products to larger population.

Principles of blood transfusion therapy

1. Whole blood transfusion o Generally indicated only for patients who need both increased oxygencarrying capacity and restoration of blood volume when there is no time to prepare or obtain the specific blood components needed. 2. Packed RBCs o Should be transfused over 2 to 3 hours; if patient cannot tolerate volume over a maximum of 4 hours, it may be necessary for the blood bank to divide a unit into smaller volumes, providing proper refrigeration of remaining blood until needed. One unit of packed red cells should raise hemoglobin approximately 1%, hemactocrit 3%. 3. Platelets o Administer as rapidly as tolerated (usually 4 units every 30 to 60 minutes). Each unit of platelets should raise the recipients platelet count by 6000 to 10,000/mm3: however, poor incremental increases occur with alloimmunization from previous transfusions, bleeding, fever, infection, autoimmune destruction, and hypertension. 4. Granulocytes o May be beneficial in selected population of infected, severely granulocytopenic patients (less than 500/mm3) not responding to antibiotic therapy and who are expected to experienced prolonged suppressed granulocyte production. 5. Plasma o Because plasma carries a risk of hepatitis equal to that of whole blood, if only volume expansion is required, other colloids (e.g., albumin) or electrolyte solutions (e.g., Ringers lactate) are preferred. Fresh frozen plasma should be administered as rapidly as tolerated because coagulation factors become unstable after thawing. 6. Albumin o Indicated to expand to blood volume of patients in hypovolemic shock and to elevate level of circulating albumin in patients with hypoalbuminemia. The large protein molecule is a major contributor to plasma oncotic pressure. 7. Cryoprecipitate o Indicated for treatment of hemophilia A, Von Willebrands disease, disseminated intravascular coagulation (DIC), and uremic bleeding. 8. Factor IX concentrate o Indicated for treatment of hemophilia B; carries a high risk of hepatitis because it requires pooling from many donors. 9. Factor VIII concentrate o Indicated for treatment of hemophilia A; heat-treated product decreases the risk of hepatitis and HIV transmission. 10. Prothrombin complex-Indicated in congenital or acquired deficiencies of these factors.

Objectives
1. To increase circulating blood volume after surgery, trauma, or hemorrhage 2. To increase the number of RBCs and to maintain hemoglobin levels in clients with severe anemia 3. To provide selected cellular components as replacements therapy (e.g. clotting factors, platelets, albumin)

Nursing Interventions
1. 2. 3. 4. 5. Verify doctors order. Inform the client and explain the purpose of the procedure. Check for cross matching and typing. To ensure compatibility Obtain and record baseline vital signs Practice strict Asepsis At least 2 licensed nurse check the label of the blood transfusion o Check the following: Serial number Blood component Blood type Rh factor Expiration date Screening test (VDRL, HBsAg, malarial smear) - *this is to ensure that the blood is free from blood-carried diseases and therefore, safe from transfusion. 6. Warm blood at room temperature before transfusion to prevent chills. 7. Identify client properly. Two Nurses check the clients identification. 8. Use needle gauge 18 to 19. This allows easy flow of blood. 9. Use BT set with special micron mesh filter. To prevent administration of blood clots and particles. 10. Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes. Adverse reaction usually occurs during the first 15 to 20 minutes. 11. Monitor vital signs. Altered vital signs indicate adverse reaction. 12. Do not mix medications with blood transfusion. To prevent adverse effects o Do not incorporate medication into the blood transfusion o Do not use blood transfusion lines for IV push of medication. 13. Administer 0.9% NaCl before; during or after BT. Never administer IV fluids with dextrose. Dextrose causes hemolysis. 14. Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets, cryoprecipitate, transfuse quickly (20 minutes) clotting factor can easily be destroyed. 15. Observe for potential complications. Notify physician.

Complications of Blood Transfusion

1. Allergic Reaction it is caused by sensitivity to plasma protein of donor antibody, which reacts with recipient antigen. o Assessments: Flushing

2.

3.

4.

5.

Rush, hives Pruritus Laryngeal edema, difficulty of breathing Febrile, Non-Hemolytic it is caused by hypersensitivity to donor white cells, platelets or plasma proteins. This is the most symptomatic complication of blood transfusion o Assessments: Sudden chills and fever Flushing Headache Anxiety Septic Reaction it is caused by the transfusion of blood or components contaminated with bacteria. o Assessment: Rapid onset of chills Vomiting Marked Hypotension High fever Circulatory Overload it is caused by administration of blood volume at a rate greater than the circulatory system can accommodate. o Assessment: Rise in venous pressure Dyspnea Crackles or rales Distended neck vein Cough Elevated BP Hemolytic reaction. It is caused by infusion of incompatible blood products. o Assessment: Low back pain (first sign). This is due to inflammatory response of the kidneys to incompatible blood. Chills Feeling of fullness Tachycardia Flushing Tachypnea Hypotension Bleeding Vascular collapse Acute renal failure

Assessment findings
1. Clinical manifestations of transfusions complications vary depending on the precipitating factor. 2. Signs and symptoms of hemolytic transfusion reaction include: o Fever o Chills o low back pain o flank pain

o headache o nausea o flushing o tachycardia o tachypnea o hypotension o hemoglobinuria (cola-colored urine) 3. Clinical signs and laboratory findings in delayed hemolytic reaction include: o fever o mild jaundice o gradual fall of hemoglobin o positive Coombs test 4. Febrile non-hemolytic reaction is marked by: o Temperature rise during or shortly after transfusion o Chills o headache o flushing o anxiety 5. Signs and symptoms of septic reaction include; o Rapid onset of high fever and chills o vomiting o diarrhea o marked hypotension 6. Allergic reactions may produce: o hives o generalized pruritus o wheezing or anaphylaxis (rarely) 7. Signs and symptoms of circulatory overload include: o Dyspnea o cough o rales o jugular vein distention 8. Manifestations of infectious disease transmitted through transfusion may develop rapidly or insidiously, depending on the disease. 9. Characteristics of GVH disease include: o skin changes (e.g. erythema, ulcerations, scaling) o edema o hair loss o hemolytic anemia 10. Reactions associated with massive transfusion produce varying manifestations

Possible Nursing Diagnosis

1. 2. 3. 4. 5. 6. 7. Ineffective breathing pattern Decreased Cardiac Output Fluid Volume Deficit Fluid Volume Excess Impaired Gas Exchange Hyperthermia Hypothermia

8. High Risk for Infection 9. High Risk for Injury 10. Pain 11. Impaired Skin Integrity 12. Altered Tissue Perfusion

Planning and Implementation

1. Help prevent transfusion reaction by: o Meticulously verifying patient identification beginning with type and cross match sample collection and labeling to double check blood product and patient identification prior to transfusion. o Inspecting the blood product for any gas bubbles, clothing, or abnormal color before administration. o Beginning transfusion slowly ( 1 to 2 mL/min) and observing the patient closely, particularly during the first 15 minutes (severe reactions usually manifest within 15 minutes after the start of transfusion). o Transfusing blood within 4 hours, and changing blood tubing every 4 hours to minimize the risk of bacterial growth at warm room temperatures. o Preventing infectious disease transmission through careful donor screening or performing pretest available to identify selected infectious agents. o Preventing GVH disease by ensuring irradiation of blood products containing viable WBCs (i.e., whole blood, platelets, packed RBCs and granulocytes) before transfusion; irradiation alters ability of donor lymphocytes to engraft and divide. o Preventing hypothermia by warming blood unit to 37 C before transfusion. o Removing leukocytes and platelets aggregates from donor blood by installing a microaggregate filter (20-40-um size) in the blood line to remove these aggregates during transfusion. 2. On detecting any signs or symptoms of reaction: o Stop the transfusion immediately, and notify the physician. o Disconnect the transfusion set-but keep the IV line open with 0.9% saline to provide access for possible IV drug infusion. o Send the blood bag and tubing to the blood bank for repeat typing and culture. o Draw another blood sample for plasma hemoglobin, culture, and retyping. o Collect a urine sample as soon as possible for hemoglobin determination. 3. Intervene as appropriate to address symptoms of the specific reaction: o Treatment for hemolytic reaction is directed at correcting hypotension, DIC, and renal failure associated with RBC hemolysis and hemoglobinuria. o Febrile, nonhemolytic transfusion reactions are treated symptomatically with antipyretics; leukocyte-poor blood products may be recommended for subsequent transfusions. o In septic reaction, treat septicemia with antibiotics, increased hydration, steroids and vasopressors as prescribed. o Intervene for allergic reaction by administering antihistamines, steroids and epinephrine as indicated by the severity of the reaction. (If hives are the only manifestation, transfusion can sometimes continue but at a slower rate.)

For circulatory overload, immediate treatment includes positioning the patient upright with feet dependent; diuretics, oxygen and aminophylline may be prescribed.

Nursing Interventions when complications occurs in Blood transfusion

1. 2. 3. 4. 5. 6. 7. 8. If blood transfusion reaction occurs. STOP THE TRANSFUSION. Start IV line (0.9% Na Cl) Place the client in fowlers position if with SOB and administer O2 therapy. The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes. Notify the physician immediately. The nurse prepares to administer emergency drugs such as antihistamines, vasopressor, fluids, and steroids as per physicians order or protocol. Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as a result of RBC hemolysis. Blood container, tubing, attached label, and transfusion record are saved and returned to the laboratory for analysis.

Evaluation
1. 2. 3. 4. 5. 6. 7. 8. The The The The The The The The patient patient patient patient patient patient patient patient maintains normal breathing pattern. demonstrates adequate cardiac output. reports minimal or no discomfort. maintains good fluid balance. remains normothermic. remains free of infection. maintains good skin integrity, with no lesions or pruritus. maintains or returns to normal electrolyte and blood chemistry values.