Assessment is the first and the most important step in the nursing process and this a precise description about it.

2. NURSING
ASSESSMENT

3. DEFINITION
Assessing is the systematic and
continuous collection, organization,
validation and documentation of data.
-Potter and Perry (2006)
Assessment is the deliberate and
systematic collection of data to determine
client’s current and past health status and
to determine the client’s present and past
coping patterns.
-Carpenito (2000)

4. PURPOSE
To establish a data base of:
Nursing health history
Physical assessment
Physician’s history and physical
examination
Lab results and diagnostic tests
Any other specifications from other
health personnel.

5. TYPES OF NURSING
ASSESSMENTS
1. Initial Assessment
2. Focused Assessment
3. Emergency Assessment
4. Time-lapsed assessment or
ongoing assessment

6. STEPS OF ASSESSMENT
1. Data collection
2. Organizing data
3. Validating data
4. Documenting data

7. DATA COLLECTION
• Gathering of information about the client
• Includes past health history of client
• Includes current/present problems of the
client

8. TYPES OF DATA
Subjective data- symptoms or
covert data
Objective data- signs or overt data

9. SOURCES OF DATA
Patient
Family and significant others
Patient record-
− Medical history, physical examination
and progress notes
− Consultations
− Reports of laboratories and other
diagnostic studies
− Reports of therapists and other
healthcare professionals

10. METHODS OF DATA
COLLECTION
 Observation
To gather data using senses
Example: - labored breathing, pallor
or flushing, pain, functioning of an
equipment
 Interviewing
An interview is a planned
communication or a conversation with
a purpose.

11. FOUR PHASES OF A
NURSING INTERVIEW
I. Preparatory phase
II. Introductory phase
III.Working phase
IV.Termination

12.  Physical assessment
− Appraisal of health
− Usually by review of systems
− Overview of symptoms
− Objective data

13. METHODS OF PHYSICAL
ASSESSMENT
Inspection
Percussion
Palpation
Auscultation

14. COMPLETE HEALTH
HISTORY
Biographical data
Reason for seeking care
History of present illness
• Past health
• Hospitalizations and surgeries
• Family history
• Review of systems

15.  ORGANISING DATA
Nurses use a written or computerized
format for arranging the data
systematically.
 VALIDATING DATA
Nurse verifies understanding of
information provided by the patient. For
validation, she may also compare the
information with other sources like
family member, health team member or
previous health records.

16.  DOCUMENTING DATA
Nurse records all the documents in a
written form. Patient’s own words are
used in subjective data enclosed in
quotation marks. No summative
statements are used.
E.g.: the nurse record the client's breakfast
intake as" coffee 240 mL. Juice 120 mL, 1
egg". Rather than as "appetite good".

17. Nsg.
assessment
Nsg.
diagnosis
Nsg.
Objective
s/goals
Planned
intervention
Rationale Implementati
on
Evaluation/
expected
outcomes
Subjective
data:
“I am not
feeling well.
My head is
aching and
burning as if
the steam
comes out of
my eyes”
Objective
data:
Flushed skin
with body
temp. of 38.1 C
per axilla, RR-
21breaths/min,
PR-
89beats/min,
unstable B.P,
chills, profuse
diaphoresis