2. INTRODUCTION
Assessment is the first step to determine health
status . It is the gathering of information to
have all the “necessary puzzle pieces ” to make
a clear picture of the person’s health status.
The entire plan of care is based on the data you
collect during this phase and make every effort
to ensure that your information is correct,
complete and organized in a way that you will
begin to get a sense of patterns of health or
illness.
3. DEFINITION OF ASSESSMENT
According to Carpenito :-Assessment is the
deliberate and systematic collection of data to
determine a client’s current and past health status
functional status and to determine the client’s
present and coping patterns.
Atkinson and murray(1991) :- Assessment is a
part of each activity the nurse does for and with
the patient.
4. PURPOSES OF ASSESSMENT
To gather information regarding client’s health.
To determine client’s normal function.
To organize the collected information.
To confirm hypothesis growing out of the nurse’s
interview.
To enhance investigation of nursing problems.
To frame nursing diagonsis.
It increases greater managing skill of handling
patient’s problem.
To identify the health problems.
To identify client’s strengths.
To identify need for health teaching.
6. INITIAL ASSESSMENT
It is performed within specified time after
admission to a health care agency.
Purpose : To establish a complete data base for
problem identification , reference , and future
comparison.
Ex :- Nursing admission assessment
7. FOCUS OR ONGOING
ASSESSMENT
Ongoing process integrated with nursing care.
Purpose : To determine the status of a specific
problem identified in an earlier assessment and
to identify new or overlooked problem.
Ex : Hourly assessment of client’s fluid intake
and output chart.
8. EMERGENCY ASSESSMENT
During any physiologic or psychologic crisis of the
client.
Purpose : To identify life-threatening problems.
Ex : A) Rapid assessment of person’s airway , breathing
status and circulation during a cardiac arrest.
B) Assessment of suicidal tendencies or potential for
violence.
9. TIME-LAPSED ASSESSMENT
Several months after initial assessment.
Purpose : To compare the client’s current status to
baseline data previously obtained.
Ex : Reassessment of a client’s functional health patterns
in a home care.
10. METHODS OF ASSESSMENT
The primary methods used to assess client’s are :
1. Observing
2. Interviewing
3. Examining
11. OBSERVING
Observation is a conscious , deleberate skill that
is developed only through and with an organized
approach.
Ex : Client data observed through four senses
that is through vision , smell , hearing and touch.
12. INTERVIEWING
An interview is a planned communication or a
conversation with a purpose.
Ex : History taking
There are two approaches for interviewing :
-Directive approach
-Non directive approach
13. EXAMINING
The physical examination is a systematic data
collection method that uses observational skills
to detect health problems.
To conduct the examination, the nurse uses
techniques of inspection, auscultation, palpation
and percussion.
16. HEAD-TO-TOE ASSESSMENT
Physical Assessment using head toe approach
General Test hearing
General health status Cranial nerves
Vital signs and weight Inspect lymph nodes
Nutrional status Inspect neck veins
Mobility and self care Chest
Observe posture Inspect and palpate breast
Assess gait and balance Inspect and auscultate lungs
Evaluate mobility Auscultate heart
Activities of daily living Abdomen
Head face and neck Inspect, auscultate, palpate four quadrants
Evaluate cognition Palpate and percuss liver, stomach, bladder
LOC Bowel elimination
Orientation Urinary elimination
Mood
Language and memory
Sensory function
Test vision
Inspect and examine ears
17. CONT…..
Extremities
Skin, hair and nails Palpate arterial pulses
Inspect scalp, hair & nails Observe capillary refill
Evaluate skin turgor Evaluate edema
Observe skin lesion Assess joint mobility
Assess wounds Measure strength
Genitalia Assess sensory function
Inspect female client Assess circulation,
Inspect male client movement, & sensation
Deep tendon reflexes
Inspect skin and nails
18. BODY SYSTEM APPROACH
Review of Systems
General presentation of symptoms: Fever, chills, malaise, pain, sleep patterns,
fatigability
Diet: Appetite, likes and dislikes, restrictions, written dairy of food intake
Skin, hair, and nails: rash or eruption, itching, color or texture change, excessive
sweating, abnormal nail or hair growth
Musculoskeletal: Joint stiffness, pain, restricted motion, swelling, redness, heat,
deformity
Head and neck:
Eyes: visual acuity, blurring, diplopia, photophobia, pain, recent change in vision
Ears: Hearing loss, pain, discharge, tinnitus, vertigo
Nose: Sense of smell, frequency of colds, obstruction, epistaxis, sinus pain, or
postnasal discharge
Throat and mouth: Hoarseness or change in voice, frequent sore throat, bleeding or
swelling of gums, recent tooth abscesses or extractions, soreness of tongue or mucosa.
19. Endocrine and genital reproductive: Thyroid enlargement or tenderness, heat
or cold intolerance, unexplained weight change, polyuria, polydipsia, changes in
distribution of facial hair; Males: Puberty onset, difficulty with erections,
testicular pain, libido, infertility. Females: Menses {onset, regularity, duration
and amount}, Dysmenorrhea, last menstrual period, frequency of intercourse, age
at menopause, pregnancies {number, miscarriage, abortions} type of delivery,
complications, use of contraceptives; breasts {pain, tenderness, discharge,
lumps}
Chest and lungs: Pain related to respiration, dyspnea, cyanosis, wheezing,
cough, sputum {character, and quantity}, exposure to tuberculosis (TB), last
chest X-ray
Heart and blood vessels: Chest pain or distress, precipitating causes, timing
and duration, relieving factors, dyspnea, orthopnea, edema, hypertension,
exercise tolerance
20. Gastrointestinal: Appetite, digestion, food intolerance,
dysphagia, heartburn, nausea or vomiting, bowel regularity,
change in stool color, or contents, constipation or diarrhea,
flatulence or hemorrhoids
Genitourinary: Dysuria, flank or suprapubic pain, urgency,
frequency, nocturia, hematuria, polyuria, hesitancy, loss in force
of stream, edema, sexually transmitted disease
Neurological: Syncope, seizures, weakness or paralysis,
abnormalities of sensation or coordination, tremors, loss of
memory
Psychiatric: Depression, mood changes, difficulty concentrating
nervousness, tension, suicidal thoughts, irritability.
Pediatrics: along with systemic approach in case of pediatrics,
measure anthropometric measurement and neuromuscular
assessment.
22. ASSESSMENT TECHNIQUES -
CONT.
INSPECTION
• Close and careful visualization of the
person as a whole and of each body
system
• Ensure good lighting Perform at
every encounter with your client
23. ASSESSMENT TECHNIQUES - CONT.
PALPATION
•Temperature, Texture,
Moisture
•Organ size and location
•Rigidity or spasticity
•Crepitation & Vibration
•Position & Size
•Presence of lumps or masses
•Tenderness, or pain
24. ASSESSMENT TECHNIQUES - CONT.
PERCUSSION
Assess underlying
structures for location,
size, density of
underlying tissue.
25. ASSESSMENT TECHNIQUES - CONT.
AUSCULTATION
•Listening to sounds produced by
the body
•Instrument: stethoscope (to skin)
Diaphragm –high pitched sounds
•Heart
•Lungs
•Abdomen
Bell – low pitched
sounds
•Blood vessels
26. ASSESSMENT PROCESS
Assessment
Organize Documenting
Collect data Validate data
data data
27. ASSESSMENT PROCESS
The assessment process involves four closely related
activities :
1. Collecting data : Process of gathering information.
A) Types of data
subjective objective
28. TYPES OF DATA
When performing an assessment the nurse gathers
subjective and objective data.
Subjective data (symptoms or covert data) : are the
verbal statements provided by the Patient. Statements
about nausea and descriptions of pain and fatigue are
examples of subjective data.
29. Objective data (signs or overt data): are
detectable by an observer or can be measured or
tested against an accepted standard. They can be
seen, heard, felt, or smelt, and they are obtained by
observation or physical examination. For example:
discoloration of the skin.
30. SOURCES OF DATA
Data can be obtained from primary or secondary sources.
The primary source of data is the patient. In most
instances the patient is considered to be the most accurate
reporter. The alert and oriented patient can provide
information about past illness and surgeries and present
signs, symptoms, and lifestyle.
When the patient is unable to supply information
because of deterioration of mental status, age, or
seriousness of illness, secondary sources are used.
31. The Secondary sources of data include family
members, significant others, medical records,
diagnostic procedures,
Members of the patient's support system may be
able to furnish information about the patient's past
health status, current illness, allergies, and current
medications.
Other health team professionals are also
helpful secondary sources (Physicians, other
nurses.)
32. ORGANIZING DATA
Cluster the data into groups of information that
help you identify patterns of health or illnesses.
The nurse uses a written or computerized format
that organizes the assessment data systematically.
The format may be modified according to the
client's physical status.
33. VALIDATING DATA
The information gathered during the assessment
phase must be complete, factual, and accurate
because the nursing diagnosis and interventions
are based on this information.
Validation is the act of "double-
checking" or verifying data to confirm that it is
accurate and factual.
34. DOCUMENTING DATA
To complete the assessment phase, the nurse records
client's data.
Accurate documentation is essential and
should include all data collected about the client's health
status.Data are recorded in a factual manner and not
interpreted by the nurse.
E.g.: the nurse record the client's breakfast
intake as" coffee 240 mL. Juice 120 mL, 1 egg". Rather
than as "appetite good".
