Nursing Process - Nursing Assessment

1. NURSING ASSESSMENT
BY
ASOKAN R,
ASSO. PROFESSOR, KINS
KIIT DEEMED TO BE UNIVERSITY

2. What Is Nursing Assessment?

3. It is a systematic, rational method of planning and
providing individualized nursing care.

4. Characteristics of Nursing Assessment
 Cyclic and dynamic
 Problem solving technique
 Open and flexible
 There is no absolute beginning
 Client centered
 Interpersonal and collaborative
 Planned

5.  Goal directed
 Permits creativity for the nurse and clients
 Emphasizes feedback
 Universally applicable
 Decision making
 Critical thinking skills
 Directed towards client response and disease

6. What you mean by Assessing?

7. Assessing
 Systematic and continuous collection, organization, validation
and documentation of data.
 Carried out during all phases.

8. TYPES
Types vary according to their purpose, timing, time available and client
status.
 Medical assessment focus on disease.
 Nursing assessment focus on client’s response to health problem.
1. Initial assessment
2. Problem focused assessment
3. Emergency assessment
4. Time lapsed assessment

9. Assessment process
Collecting data
Organizing data
Validating data
Documenting data

10. Collecting data
 Process of gathering information about a client’s health status.
 Database – all the information about client.
Nursing history
Physician’s history and physical examination
Results of laboratory and diagnostic tests
Materials contributed by other health personal.

11. TYPES OF DATA
 Subjective data (symptoms or covert data)
 Client’s sensations, feeling, values, beliefs, attitude, perception
of personal health status and life situation.
 Objective data ( sign or overt data)
 Seen, heared, felt, smelled, observed and physical examination.

12. SOURCE OF DATA
 Primary ( client)
 Secondary ( family member, other support persons, other health
professionals, records and reports, laboratory & diagnostic
analysis & relevant literature.
client ( too ill, young, confused)
support people ( unconscious, physically and emotionally
abused)
client records ( medical, therapies & laboratory records)

13. Health care professionals ( nurses, social workers, physicians &
physiotherapist)
literature ( professional journals & reference texts)
standard ( compare)
cultural & social health practices
spiritual beliefs
Additional required assessment data (WHO)
Nursing interventions and evaluation criteria
Information about medical diagnosis, treatment and prognosis.

14. DATA COLLECTION METHOD
 Observing
 Interviewing
 Examining

15. OBSERVING ( FIVE SENSES)
 Noticing the stimuli
 Selecting, organizing & interpreting data.
(body temperature, activity, BP & environmental temperature)
 Distinguishing the stimuli should be meaningful.
 Experienced nurse.
Example:
clinical signs of distress
Clients safety
Immediate environment

16. INTERVIEWING
 Planned communication or a conversation with a purpose
 Two approaches
 Direct interview – highly structured and elicited specific information
(emergency situations)
 Nondirective interview – rapport building interview, asking open
ended questions.
 Combination of directive & Nondirective – information gathering
interview (client express worry about surgery)

17. Kinds of interview questions
Closed / open ended questions
Neutral / leading questions
 Closed ended questions : yes / No
 When, where, who, what, do, is, how.
 Open ended questions
invite the clients to freedom to talk, broad topic to be discussed, response,
clients attitude & beliefs
example: How do you feel?
need of the nurse will choose.

18.  Neutral questions
 Client can answer without direction or pressure from the nurse
Example: Why do you think you had the operation?
 Leading questions
 Question suggests what answer is expected less opportunity to
decide.
Example: you are stressed about surgery tomorrow. Are not
you?

19. Planning the interview
(review available information)
 Time, place, seating arrangement.
 Time – freedom of pain, physically comfortable, no interruptions &
unhurry.
 Seating arrangement – create formal setting, with no table between, create
less formal atmosphere, feel equal both, circular chair arrangement can
avoid.
 If bed – 45 degree angle, position is less formal, overbed table between
the clients and nurse.
 Distance – neither too small nor too great, 3 to 4 feet distance

20. Stages of interviews
 Establishing rapport – begin with greeting ( good morning ), self
introduction, accompanied nonverbal gestures, continue rapport
development.
 Careful not to overdo this stage, too much superficial talk will
make anxiety.

21.  Orientation stage – explain the purpose, nature of interview
(what information is needed)
 Body – communicate, thinks, feels, knows & open ended
questions.
Use communication technique.
 Closing – when needed information obtained, when decided not
to give any more information, unable to offer more information
e.x: fatigue.
facilitating future interactions.

22. EXAMINING
 Physical exam (systematic data collection methods that uses
observational skills.
 Use techniques of inspection, palpation, percussion &
auscultation.
 Head to toe approach
 Body system examination
 Screening examination.

23. ORGANIZING DATA
 Nursing health history, Nursing assessment.
 The framework may be modified according to the clients physical
status.
 Health care agencies have developed their own structured
assessment tools.
Gordon’s functional health pattern framework
Orem’s self-care model
Roy’s adaptation model.

24. VALIDATING DATA
 Data must be complete, factual & accurate.
 Validation is “double checking or verifying data to conform
accurate & factual”.
 It helps,
Information complete
Ensure objective & subjective data agree
Obtained additional information

25.  Differentiate between cues & inferences.
Cues – subjective/objective data that can be directly observed
by the nurse.
can see, hear, feel, smell & measure.
Inferences – nurse’s conclusion / interpretation of the cues.
e.x: a nurse observes the cues that an incision is red, hot &
swollen.
Inference that incision is infected.

26. GUIDELINES
I. Compare subjective & objective data
E.x: feeling hot – measure body temperature
II. Clarify any ambiguous or vague statements
E.x: I have felt sick on and off 6 months.
Describe what your sickness is like & what you mean by on & off.
III. Be sure your data consist cues and not inference
E.x: dry skin & reduced tissue turgor.
Dehydration.
So collect additional information.

27. IV. Double check the data that are extremely abnormal.
E.x; resting pulse of 50 b/m or BP of 180/95 mm Hg. So use another
equipment or someone else do.
V. Determine the presence of factors that may interfere with accurate measurement.
Eg: crying infant will have abnormal respiration rate. So need quieting
before accurate assessment.
VI. Use references to explain phenomena. ( textbooks, journals, research reports)
Eg: tiny purple or bluish black swollen area under the tongue of an elderly
patient to be abnormal until reading about physical changes of aging.

28.  Not all data require validation (height, weight, date of birth
& laboratory studies)
 Only need validation in any discrepancies between data
obtained.
 Aware about values & beliefs
 Avoid premature closure.

29. DOCUMENTING DATA
 Recorded in a factual manner & not interpreted by the nurse.
E.x: coffee 240 ml, juice 120 ml, 1 egg, 1 slice of toast rather than
“appetite good” ( judgement).
 Judgment or conclusion such good appetite or normal
appetite may have differences.
 Subjective data in the clients own words.

30. thank u