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nursing assessment


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nursing assessment

  2. 2. INTRODUCTION Assessment is the first step to determine healthstatus . It is the gathering of information tohave all the “necessary puzzle pieces ” to makea clear picture of the person’s health status.The entire plan of care is based on the data youcollect during this phase and make every effortto ensure that your information is correct,complete and organized in a way that you willbegin to get a sense of patterns of health orillness.
  3. 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. 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.
  5. 5. TYPES OF ASSESSMENT AssessmentInitial Focus Emergency Time-lapsedAssessment Assessment Assessment Assessment
  6. 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. 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. 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. 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. 10. METHODS OF ASSESSMENT The primary methods used to assess client’s are : 1. Observing 2. Interviewing 3. Examining
  11. 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. 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. 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.
  15. 15. ASSESSMENT SEQUENCING • Head – to - Toe Assessment • Body Systems Assessment
  16. 16. HEAD-TO-TOE ASSESSMENT Physical Assessment using head toe approachGeneral Test hearingGeneral health status Cranial nervesVital signs and weight Inspect lymph nodesNutrional status Inspect neck veinsMobility and self care ChestObserve posture Inspect and palpate breastAssess gait and balance Inspect and auscultate lungsEvaluate mobility Auscultate heartActivities of daily living AbdomenHead face and neck Inspect, auscultate, palpate four quadrantsEvaluate cognition Palpate and percuss liver, stomach, bladderLOC Bowel eliminationOrientation Urinary eliminationMoodLanguage and memorySensory functionTest visionInspect and examine ears
  17. 17. CONT….. ExtremitiesSkin, hair and nails Palpate arterial pulsesInspect scalp, hair & nails Observe capillary refillEvaluate skin turgor Evaluate edemaObserve skin lesion Assess joint mobilityAssess wounds Measure strengthGenitalia Assess sensory functionInspect female client Assess circulation,Inspect male client movement, & sensation Deep tendon reflexes Inspect skin and nails
  18. 18. BODY SYSTEM APPROACHReview 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, excessivesweating, 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, orpostnasal discharge Throat and mouth: Hoarseness or change in voice, frequent sore throat, bleeding orswelling of gums, recent tooth abscesses or extractions, soreness of tongue or mucosa.
  19. 19. Endocrine and genital reproductive: Thyroid enlargement or tenderness, heator cold intolerance, unexplained weight change, polyuria, polydipsia, changes indistribution of facial hair; Males: Puberty onset, difficulty with erections,testicular pain, libido, infertility. Females: Menses {onset, regularity, durationand amount}, Dysmenorrhea, last menstrual period, frequency of intercourse, ageat 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), lastchest X-ray Heart and blood vessels: Chest pain or distress, precipitating causes, timingand duration, relieving factors, dyspnea, orthopnea, edema, hypertension,exercise tolerance
  20. 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 forceof stream, edema, sexually transmitted disease Neurological: Syncope, seizures, weakness or paralysis,abnormalities of sensation or coordination, tremors, loss ofmemory Psychiatric: Depression, mood changes, difficulty concentratingnervousness, tension, suicidal thoughts, irritability. Pediatrics: along with systemic approach in case of pediatrics,measure anthropometric measurement and neuromuscularassessment.
  21. 21. ASSESSMENT TECHNIQUES• Inspection• Palpation• Percussion• Auscultation
  22. 22. ASSESSMENT TECHNIQUES - CONT. INSPECTION• Close and careful visualization of theperson as a whole and of each bodysystem• Ensure good lighting Perform atevery encounter with your client
  23. 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. 24. ASSESSMENT TECHNIQUES - CONT. PERCUSSIONAssess underlyingstructures for location,size, density ofunderlying tissue.
  25. 25. ASSESSMENT TECHNIQUES - CONT. AUSCULTATION•Listening to sounds produced bythe body•Instrument: stethoscope (to skin)Diaphragm –high pitched sounds •Heart •Lungs •Abdomen Bell – low pitched sounds •Blood vessels
  26. 26. ASSESSMENT PROCESS Assessment Organize DocumentingCollect data Validate data data data
  27. 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. 28. TYPES OF DATAWhen performing an assessment the nurse gatherssubjective and objective data.Subjective data (symptoms or covert data) : are theverbal statements provided by the Patient. Statementsabout nausea and descriptions of pain and fatigue areexamples of subjective data.
  29. 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. 30. SOURCES OF DATAData can be obtained from primary or secondary sources. The primary source of data is the patient. In mostinstances the patient is considered to be the most accuratereporter. The alert and oriented patient can provideinformation about past illness and surgeries and presentsigns, symptoms, and lifestyle. When the patient is unable to supply informationbecause of deterioration of mental status, age, orseriousness of illness, secondary sources are used.
  31. 31. The Secondary sources of data include familymembers, significant others, medical records,diagnostic procedures,Members of the patients support system may beable to furnish information about the patients pasthealth status, current illness, allergies, and currentmedications. Other health team professionals are alsohelpful secondary sources (Physicians, othernurses.)
  32. 32. ORGANIZING DATACluster the data into groups of information thathelp you identify patterns of health or illnesses.The nurse uses a written or computerized formatthat organizes the assessment data systematically.The format may be modified according to theclients physical status.
  33. 33. VALIDATING DATAThe information gathered during the assessmentphase must be complete, factual, and accuratebecause the nursing diagnosis and interventionsare based on this information. Validation is the act of "double-checking" or verifying data to confirm that it isaccurate and factual.
  34. 34. DOCUMENTING DATATo complete the assessment phase, the nurse recordsclients data. Accurate documentation is essential andshould include all data collected about the clients healthstatus.Data are recorded in a factual manner and notinterpreted by the nurse. E.g.: the nurse record the clients breakfastintake as" coffee 240 mL. Juice 120 mL, 1 egg". Ratherthan as "appetite good".