NR 305 Discussion Assessment Techniques

This week’s lesson focuses on assessment of families and introduces specific assessment opportunities for racially diverse, same sex, and adoptive families. Select one of these three non-traditional families. How would your assessment technique change to be sure that you were competently caring for a member of this type of family unit? This may include questions you would add to the health history, or ways in which you would communicate.

I did the alternative assignment and I believe that there is a time to gather all that information, but that inpatient during an initial assessment, we may not have that time. Our hospital system goes over a checklist. Half the time I am interrupted by a doctor coming in to do his assessments. Funny thing is that my background information may end up helping the doctors a bit getting to know the patient, but they have more patients than I do.

As a new nurse, I was more task oriented and focused on getting all my check marks done. Now I have the initial assessment memorized so that I could even ask the right questions if my computer was not functioning to fill in later. Attentiveness as well as trying to get through that assessment efficiently is important to getting into the care that the patient needs. I often find myself having small talk with patients to talk about where they are from, family life, etc. while passing meds or maybe just getting up to go to the bathroom.

If there is a way to address someone properly, that is a way to instantly build rapport. Let us say I have a patient who identifies as lesbian and her significant other is her “spouse”, “partner”, or “wife”, I can then respectfully and correctly honor that relationship. Simple validation goes a long way. Also recognizing these people as a family or couple is important in assessment. Something we always ask our patients about during our initial assessment is whether the patient is living in a safe and unthreatening environment. Those intimate questions are asked privately and without a domestic partner in the room (Weber & Kelley, 2018). A lesbian patient needs to be asked those questions just the same as a heterosexual patient. In fact, according to Mick (2006) “gay male couples and lesbian couples have similar prevalence rates and similar patterns of abuse as heterosexual couples”. Ignorance may make assumptions about the patient in the room, but we cannot know about a person unless we ask questions and actually assess that patient.

References

Mick, J. (2006). Identifying signs and symptoms of intimate partner violence in an oncology setting. Clinical Journal of Oncology Nursing 10(4): 509-523.

Weber, J.R. & Kelley, J.H. (2018). Health assessment in nursing (6th ed.). Philadelphia, PA: Wolters Kluwer.

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If there is a way to address someone properly, that is a way to instantly build rapport. Let us say I have a patient who identifies as lesbian and her significant other is her “spouse”, “partner”, or “wife”, I can then respectfully and correctly honor that relationship. Simple validation goes a long way. Also recognizing these people as a family or couple is important in assessment. Something we always ask our patients about during our initial assessment is whether the patient is living in a safe and nonthreatening environment. Those intimate questions are asked privately and without a domestic partner in the room (Weber & Kelley, 2018). A lesbian patient needs to be asked those questions just the same as a heterosexual patient. In fact, according to Mick (2006) “gay male couples and lesbian couples have similar prevalence rates and similar patterns of abuse as heterosexual couples”. Ignorance may make assumptions about the patient in the room, but we cannot know about a person unless we ask questions and actually assess that patient.

References

Mick, J. (2006). Identifying signs and symptoms of intimate partner violence in an oncology setting. Clinical Journal of Oncology Nursing 10(4): 509-523.

Weber, J.R. & Kelley, J.H. (2018). Health assessment in nursing (6th ed.). Philadelphia, PA: Wolters Kluwer.

When I first began my assessments in clinical rotation, I was extremely nervous and often missed steps. I must admit I took a long time, and this really agitated the patients. There were times where I even had to go back into the room to assess the patient again because I skipped an important part of the assessment. In comparison to my performance today, I can now perform an assessment with confidence and finish in less than half the time I spent in the past. It comes more natural for me now and I usually do not skip any areas to physically assess. I find that I can now hold a casual conversation with the patient, and this makes my assessment flow a lot better now. The patient responses are a lot more positive than in the past. Weber & Kelley 2018 states, “The more you practice, the faster you will perform the assessment” (Weber & Kelley, 2018, p. 672).

Based on observation I feel that assessments performed in practice are not always as through as they should be. I have noticed patients arriving from the Emergency Department with critical missed findings like skin integrity, muscle strength, and mobility. Being that the Emergency Department is often a fast-paced and chaotic setting, I can understand how this may happen. However, that is when I realize my assessment must be very through and non-reliant on another nurse’s findings. While I was working as a unit clerk on a medical surgical unit, I observed a situation that I will never forget. A new admission arrived on the unit and the nurse who accepted the patient went in to perform her assessment. I happened to be walking by the room, and the nurse called me over. She said the patient was difficult to rouse and she needed assistance immediately from the other nurses. I took a glance at the patient, and she was sitting up and appeared lifeless with a glazed look in her eyes. I immediately ran to the nurses’ station to get help seeing as the situation looked serious. After all the commotion that followed it turned out the patient’s blood sugar was dangerously low. The hospitalist came, the patient was given a bolus and she ended up being transferred to the critical care unit. What followed was a lot of conversations on the unit on how the Emergency Department sent the patient up without assessing her critical condition before transport. This is something that I will never forget, and it reminds me how important the reassessment is in providing patient care.

If I were assessing a same-sex family, my technique would need to be sensitive, respectful, and attentive toward enhancing therapeutic communication. To build on self-esteem and communication, as stated in Weber & Kelley 2018, “offer at least one or two commendations during each meeting with family” (Weber & Kelley, 2018, p. 861). I would commend the family for their strengths and efforts based on information provided during the assessment. This would build up their self-esteem and hopefully make them feel open to sharing further information. I believe it would be critical to determine the gender roles in the family and not make any assumptions. As mentioned in Weber and Kelley 2018, “Ask each family member the following: What are the expected behaviors for men in your family? For women?” (Weber & Kelley, 2018, p. 862). Some small techniques that can help make the family feel respected are asking their preferred name or how they would like to be addressed. Making the family feel safe and ensuring necessary areas are uncovered for referrals and support groups are essential in providing quality care. I was saddened to learn that, “The health disparities among LGBTQI patients range from bullying and physical assault to refusal of healthcare and housing” (Landry, 2017, p. 42). One must recognize the long history of discrimination and how it has impacted this population in the health care environment. I believe providing a safe and judgement free environment would be critical in providing competent care to same-sex families.

Resources:

Weber, J.R. & Kelley, J.H. (2018). Health assessment in nursing (6th ed.). Wolters Kluwer.

Landry, J. (2017). Delivering culturally sensitive care to LGBTQI patients. The Journal for Nursing Practitioners. 13(5). P. 342-347. doi: https://doi.org/10.1016/j.nurpra.2016.12.015

I have too have had the experience where i had to return to a patient because I missed an important part of my assessment and I do agree with your quote from Weber & Kelly the more you practice the better you become. I can also relate with your experience with the patients status change and it being missed by the prior department. I had a patient pass out while walking because she was bleeding internally from a recent surgery and when she returned from the OR the nurse wanted her up and moving and did not preform a proper assessment. The patient returned to the OR and was ultimately fine but it definitely was a scary situation for both myself and the patient. This experience will stay with me throughout my career. I also appreciate the points you discussed with same sex families concerning the different gender roles of each family member and not assuming. This is an important point. It is sad to learn about the health disparities you have listed. It scares me for my own children and their future in this world. Very informative post!

You bring up SUCH an important topic–your coworkers. Everyone has worked with that nurse who is just not the strongest. As a charge nurse, that impacts how you make assignments. As the oncoming nurse, that impacts how to plan your care–maybe you need to see those patients first.

In my opinion, it is inevitable that someone might pick up on something that the previous nurse didn’t once in a while because: a) pt status changes b) we are all people and sometimes miss things. The main thing is that nothing major is missed that causes harm to a patient. Even if that is the case, most facilities now view it as an opportunity to look at process improvement rather than cause employees to be reprimanded.

In order to prevent this from happening, many units now do a bedside shift change report. For those of you who do this, how has this impacted your care? What are the pros and cons? Thank you for a great discussion and any additional thoughts!

Unfortunately, I have few gay or lesbian friends that were out-rightly accepted by their parents when they came out. There was some abuse/domestic violence that happened with a friends father when he came out which was shockingly later forgiven by my friend. I was the one who picked him up when his father literally punched him for sharing that he had a boyfriend. His father was a man I felt completely comfortable around prior, I would go watch football games at their house or just hang out. After that I could not see his face. My friend has a bigger heart than I do. 🙁

One friend of my neighbors came out as lesbian and her parents decided to pull her from high school and keep her away from people. She ended up inpatient after hurting herself.

The bullying is out there in public, but it unfortunately starts sometimes at home. Thankfully as a society we are moving away from being as judgmental and becoming more accepting of people who do not fit the cookie cutter mold.

I can relate to the unexpected surprises that come from the ED. One of the first days I was on my own I got report from the ED on a patient with no mention of the patient having a left BKA. To my surprise, not only did he have a BKA, but pedal pulses and cap refill were charted on both feet by the ED nurse. I called back down to the ED and spoke with the nurse and she said that she knew about it and apologized for not including it in the report. I told her about the charting of pedal pulses and she said she just was so busy she wasn’t paying attention. As a new nurse, I was shocked and could not understand how you can make that mistake. However, after being a nurse for only two years, I can see how things can get mis-charted. The amount of charting required and the repetitiveness has been shown to reduce individualization because charting has become a lot of “box-clicking” (Presley & Jones, 2017). I have had to correct my charting because I was charting on the wrong patient. I had the chart open to one patient and was thinking of a different patient. The good thing about making these mistakes is that we learn from them and share our mistakes so others can learn as well.

Presley, C., & Jones, L. (2017). practice Challenge: Nursing Documentation in a Box-Clicking World. Tennessee Nurse, 80(3), 11.

I could not agree more with your view of wanting to provide a judgement free and welcoming environment. I think in our career as nurses, that is one of the most important things that we can do. When I worked in a pediatric hospital I frequently encountered same sex parents who were there with their baby. I am so thankful to be able to say I never saw any staff treat them differently than heterosexual couples. However, I am sure that is not always the case like you and some of the others have mentioned in this post. I would always want to convey to any patient or family member that I am there to help them heal and not hurt. I would expect the same from any of my fellow nurses, as regardless of our own beliefs, we should not treat our patients differently based on theirs. Thank you for a great post and discussion.

Reflecting on my assessment video, first and foremost I would like to say that I was somewhat terrified doing it. It is completely one thing to be working as a nurse, knowing it is my duty to complete a thorough assessment for each of my patients to complete the best care possible I can for them and feeling confident, on the other hand having to film myself doing something I honestly do every single day like clock work still felt out of place and at times not even correct. It is weird to realize that something we do every single day doesn’t necessarily phase us, but then knowing that people are watching it can cause anxiety and doubt. I do remember feeling this exact same way when I was a brand new nurse with my own patient load and responsibilities for their lives and care. There were so many times I doubted my abilities because of not having the experience behind it. Since I have been working in a specialty area for the last 5 years it was definitely a huge reminder on how our assessment is specific to what we have done surgically to the patient and we don’t really do the complete head to toe assessment as doing for this assignment. It reminds me how important each part of the complete physical assessment is to be able to give holistic care to the patient. I appreciate the refresher for sure!
1. I do feel the assessment we completed for the assignment was thorough. Within the assessment I realized there were some areas where I could have and actually did expand on parts of the assessment. With any specialty there are focused assessments that are completed outside of the normal head to toe. So of course with this there is always constant opportunity to tweak, learn or improve on assessments to give better care to the patient.
1. Definition of family is “considered two or more individuals who depend on one another for emotional, physical and economic support.” (Weber, Kelley, 2018) This is important as it includes single-parent, extended, communes, gay/lesbian couples and multigenerational families. Each member of these families is considered to be “self-defined.” I would choose to discuss a same sex family. The diversity of this is not complicated, however when making assessment things need to be noted during history information (verifying if any of the children are biologically either parents’ children, if they have any health history background for the other biological parent). You must be diligent that the children could very well be adopted and this could also run into issues for the kids when it comes to health history. Understanding these family dynamics is important to support each member and have open lines of communication. Research has shown that using diverse family literature when trying to care for children is extremely beneficial for the children to comprehend and understand their importance and that their family is no different than anyone else’s. (Peterschick-Gilmore, Bell, 2006) Being able to make all parts of the family comfortable during any interaction is extremely important and since we as nurses value the ability of educating our patients finding relatable literature, pamphlets, etc could be of great value.

References:

Weber, J., Kelley, J., (2018) Assessing families. Health Assessment in Nursing. 13. 855

Peterschick-Gilmore, D., Bell, K., (2006). We are family: using diverse family structure literature with children. Reading Horizons. 46, (4). 279-299. Retrieved from: https://eds-a-ebscohost-com.chamberlainuniversity.idm.oclc.org/eds/pdfviewer/pdfviewer?vid=3&sid=cd69861c-1766-4aa0-8931-1b92e0f586da%40sdc-v-sessmgr03Links to an external site.

I also wrote about assessing a same-sex family in my post. I really like your suggestion to incorporate diverse family literature. I like when you mentioned using literature to help the child understand their family is no different than anyone else’s. I think its important for the child to see there are other families like their own as well.

Another good suggestion I found while researching this topic was to build up the family. According to Weber and Kelley 2018, “The individual or family can be commended on strengths, resources, or competencies observed or reported to the nurse” (Weber & Kelley, 2018, p. 861). I think its important to help the family to recognize their strengths and efforts are so important. This will encourage further efforts and positive behaviors. As well as build their self-esteem as a unit.

Resource:

Weber, J.R. & Kelley, J.H. (2018). Health assessment in nursing (6th ed.). Wolters Kluwer.

Since I did not do the video assessment, I am only able to go off of the alternate assignment which was more of an interview assessment. Part of the assessment was to ask about the family history of three generations. Doing this reminded me how important family history could be when it comes to health. Not only are many diseases genetic, but some diseases are brought on my lifestyle and environment (Weber & Kelley, 2018). For example, if one of your parents are obese and have high blood pressure and diabetes, it may indicate that there are unhealthy eating habits in the home which puts everyone at risk. As a nurse in a hospital, we are naturally more focused on the immediate concern of the patient, but in reality, we should be looking at so much more.

I feel the interview assessment I performed was very thorough, but it was missing a few things that I felt was important. It did not ask about diet or exercise, both which are very important to maintaining good health. The only reason I knew the participants diet and exercise habits were because they were part of his health goals.

I chose to focus on adoptive families for this week’s discussion. Adopted children present a different type of challenge because you might not know the family history of the child. There is also the issue of attachment problems that may exist. A friend of mine adopted an older child from an orphanage in Russia who had attachment and trust issues. He had an asthma attack and had to stay overnight in the hospital which was very difficult for both him and his family. Because his history of being left, he would not let his mom leave his side for even a minute. The lack of history and attachment issues are real concerns for adoptive families and some feel that those issues are not taken into consideration by healthcare providers (Smit, Delpier, Tarantino, & Anderson, 2006).

References

Smit EM, Delpier T, Tarantino SF, & Anderson ML. (2006). Caring for adoptive families: lessons in communication. Pediatric Nursing, 32(2), 136–143.

Weber, J.R. & Kelley, J.H. (2018). Health assessment in nursing (6th ed.). Wolters Kluwer.

1. Reflect on the assessment you performed for the video assignment. Perhaps you might compare your performance now, to how it might have been different when you were a brand new nurse? Or share something you learned (or were reminded of) by participating in this activity?

I wasn’t able to do the video assignment, but assessment techniques can vary depending on what category of family or patient you have presented to you, it’s the nurses part to adjust. I’m still a nursing student, but I guess I can answer this question to how I would interview now compared to when I first started school. It’s much different, before I would have just got all the facts like a straight forward interview and that’s it. Now I’m getting better at being much more aware of telling if the patient is uneasy or isn’t fully telling all of the story. Now every patient or family is different on how to approach it whether it be in a blended family, adopted children, same sex parents, single parent families. “Children can be adopted by family members, a single-parent family, or two parents of the opposite or same sex.” I feel like because of this, it is more likely to be seen including same sex families. I’ve learned that you can never be sure of anything in terms of where a patient is coming from in their family background and culture, you have to approach it with respect. “Communication theory concerns the sending and receiving of both verbal and nonverbal messages.”(p.860). For me I’ve learned to be able to pick up on a lot more body language than actual verbal communication. It’s kind of funny to think about, but I watched a tv show a long time ago called “lie to me” it’s a great tv show, but it basically focused on how body language and more so someone’s facial expressions can tell a lot more than what they are saying. The same thing is what I look for while talking to patients, even if it’s as simple as asking if they feel any any, the patient says no, but their face slightly makes a wincing face it could mean that they are in pain. So this was very important for me to be able to pick up on the small details like that.

References:

Weber, J.R. & Kelley, J.H. (2018). Health Assessment in Nursing (6th ed.). Wolters Kluwer. https://eds-b-ebscohost-com.chamberlainuniversity.idm.oclc.org/eds/detail/detail?vid=0&sid=95be0841-34c3-4522-b478-497e0fef2f9e%40pdc-v-sessmgr06&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=99041601&db=edbLinks to an external site.

NR 305 Discussion Assessment Techniques