nursingassessment-220411150937.pdf

1. The Nursing Process
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2. Nursing Assessment:
• Assessment is the first step of nursing process.
• Assessing is the systematic and continuous
collection, organization, validation and
documentation of data.
• This includes data about person’s physical and
psychological status or study of the patient as a
whole to identify his strengths and weakness and
his needs and problems
• Nursing assessment does not focus upon disease
as do medical assessment. It is based on a board
scientific knowledge, keen observation and
purposeful listening. 2

3. • 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 a clients current and
past health status and to determine the clients
present and past coping patterns
• Carpenito 2000
• Assessment is the systematic and continuous
collection, validation and communication of patient
data.
• Carol Taylor
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4. Contd…..
• It starts with the admission of the patient and
continues while the patient is under the care of the
nurse
• Continuous assessment helps to modify the nursing
care plan according to the changing needs of the
patient.
• There are four different types of assessment:
A) Initial / comprehensive assessment
B) Problem-Focused assessment
C) Emergency assessment
D) Time-lapsed reassessment
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5. 1. Initial / comprehensive assessment: An initial
assessment, also called an admission assessment, is
performed when the client enters a health care
from a health care agency.
The purposes are to evaluate the client’s health status,
to identify functional health patterns that are
problematic, and to provide an in-depth,
comprehensive database, which is critical for
evaluating changes in the client’s health status in
subsequent assessments.
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6. • 2. Problem-Focused assessment: A problem focus
assessment collects data about a problem that has
already been identified. This type of assessment has a
narrower scope and a shorter time frame than the
initial assessment. In focus assessments, nurse
determine whether the problems still exists and
whether the status of the problem has changed (i.e.
improved, worsened, or resolved).
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7. 3. Emergency assessment: Emergency assessment
takes place in life-threatening situations in which the
preservation of life is the top priority. Time is of the
essence rapid identification of and intervention for
the client’s health problems. Often the client’s
difficulties involve airway, breathing and circulatory
problems (the ABCs).
Emergency assessment focuses on few essential health
patterns and is not comprehensive.
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8. 4. Time-lapsed reassessment: Time lapsed
reassessment, another type of assessment, takes
place after the initial assessment to evaluate any
changes in the clients functional health. Nurses
perform time-lapsed reassessment when substantial
periods of time have elapsed between assessments
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9. Purposes of Assessment
• To establish baseline information on the client
• To determine the client’s risk for dysfunction or to
identify the life-threatening problem
• To determine the client’s strength
• To provide data for diagnosis
• To identify the patient’s problems
• To compare the client’s current status to baseline data
previously obtained.
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10. Methods of Assessment
• Interview (History taking)
• Physical examination
• Review of clinical records
• Consultation
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11. Assessment consists of 4 separate
activities
• Data collection
• Data organization
• Data validation
• Documenting data
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12. a. Data Collection
• Data collection is the process of gathering information
about a client’s health status.
• It must be both systematic and continuous to prevent
the omission of significant data and reflect a client’s
changing health status.
• A database is all the information about a client; it
includes the nursing health history, physical
assessment, and primary care providers’ history,
results of laboratory and diagnostic tests and
material contributed by other health personnel.
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13. Types of data
• The information that is collected during assessment is
called data. There are two types of data.
• Subjective data
• Objective data
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14. 14

15. 1. Subjective data:
• Subjective data, also referred to as symptoms or
covert data
• It consists of information given by the patient or his
relatives to the nurse as in history taking
• It is given from the patient’s or relative’s own point of
view
• It is also gathered during daily contacts with the
persons
• The symptoms that the patients complains are the
examples of the subjective data. For e.g. “I have a
fever”, “I could not sleep at night”, “My legs are
swollen”, feeling of sadness, blurring vision, pain etc.
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16. Contd…
2. Objective data:
• Objective data, also referred to as signs or overt
data
• The information about the person obtained by the
nurses through observation or physical
examination or various tests
• They can be seen, heard, felt, or smelled. For
example, a discoloration of the skin or a blood
pressure reading are objective data.
• These data are considered objective because the
data are found to be the same by any observer
• The signs which the examiner finds in the patient
are the objective data, e.g. temperature 39 ͦC,
bluish discoloration of nail-bed. Etc..
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17. Sample application: types of data
Mrs. Shisu, age 47, has come to the clinic after“passing
out” twice in the last 2 days. She tells the nurse that
she becomes “light headed” after almost any type of
activity. She has experienced some nausea since
yesterday and vomited after eating breakfast this
morning. She also tells the nurse that she is very
nervous about these occurrences because she
remembers her mother having similar symptoms
when the mother suffered from a brain disorder. The
nurse observes that the client’s gait is unsteady and
her skin is pale. The client also has large bruises on
her right arm and the right side of her face, which she
states occurred when she fell.
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18. Types of data
Subjective
• Report of fainting
• Complaint of dizziness
• Nausea
• Verbalization of anxiety
• Self-reported fall
Objectives
• Vomiting
• Unsteady gait
• Pale skin
• Bruises on right side of face
• and right arm
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19. Sources of data:
Sources of data are primary or secondary. The client is
the primary source of data.
1. Primary sources-
• The information collected from the client is
considered to be the most reliable, unless the patient
is semi conscious, has physical and mental problems.
2. Secondary sources-
• Family members or other support persons, other
health professionals, record and reports, laboratory
and diagnostic analysis, and relevant literature are
secondary or indirect sources.
• Infact, all sources other than the client are considered
secondary sources.
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20. • Characteristics of data
• Complete
• Factual
• Accurate
• relevant
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21. Contd…
Data collection methods
The principle methods used to collect data are:
• Observing
• Interviewing
• Examining
• Diagnostic and laboratory test
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22. Contd….
1. Observing:
• To observe is to gather data by using the senses.
• Observation is a conscious, deliberate skill that is
developed through effort and with an organized
approach.
• Although nurses observe mainly through sight, most
of the senses are engaged during careful
observations. By carefully watching the client, the
• nurse can detect nonverbal cues that indicate a
variety of feelings, including presence of pain, anxiety,
and anger. Observational skills are essential in
detecting the early warning signs of physical changes
(e.g., pallor and sweating).
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23. • Observation has two aspects:
a) noticing the data and
b) selecting, organizing, and interpreting the data.
• A nurse who observes that a client’s face is flushed must relate that
observation to findings such as body temperature, activity,
environmental temperature, and blood pressure.
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24. Contd…..
2. Interviewing:
• An interview is a planned communication or a
conversation with a purpose. For example, to get or
give information, identify problems of mutual
concern, evaluate change, teach, provide support, or
provide counseling or therapy.
• One example of the interview is the nursing health
history, which is a part of the nursing admission
history.
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25. • An interview is a therapeutic interaction that has a
specific purpose.
• The purpose of the assessment interview is to collect
information about the client’s health history and
current status in order to make determinations about
the client’s health needs.
• Effective interviewing depends on the nurse’s
knowledge and ability to skillfully elicit information
from the client using appropriate techniques of
communication.
• Observation of nonverbal behavior during the
interview is also essential to effective data collection.
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26. 26

27. Contd…
3. Examining:
• Physical examination or physical assessment is a
systematic data collection method that uses
observation.
• To conduct the examination the nurse uses technique
of inspection, palpation, percussion and auscultation.
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28. 4. diagnostic and laboratory test
• Results of laboratory and diagnostic tests can be
useful objective data as these values often serve as
defining characteristics for various altered health
states; these can also be helpful in ruling out certain
suspected problems.
• For example, diabetic clients who are poorly
controlled on diet and/or medication will usually have
an elevated blood glucose level.
• The pattern of these types of variations is useful in
determining a plan of care. In addition, the
effectiveness of nursing and medical interventions
and progress toward health restoration are often
monitored through laboratory and diagnostic test
data.
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29. Analysis of Data
• Identify abnormal findings
• Cluster findings into logical groups
• Localize findings anatomically
• Localize findings into probable process:
• Pathological – such as inflammatory, metabolic,
degenerative…
• Pathophysiological – mal functioning, such as
congestive heart failure…
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30. Analysis cont…
• Psychopathological – behavioral, mood disorder, thought
process disturbance
• Construct a working hypothesis from the central findings
• Match the findings with all causative conditions you know
could as associated
• Eliminate hypothesis that fail to explain the findings
• Weight the probabilities & select the most likely diagnosis
• Consider life-threatening & treatable situations
• Test the hypothesis or obtain further studies
• Establish a working definition of the problem
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31. Documentation of Data
• Permanent medico legal record of the patient’s
health status & treatment
• Record pertinent/relevant positive findings –
abnormal findings
• Record pertinent negative findings – normal
findings, or absence of abnormal findings
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32. b. Organizing Data:
• The nurse uses a written format that organizes the
assessment data systematically.
• The nurse organizes, or clusters, the information
together in order to identify areas of strengths and
weaknesses.
• This process is known as data clustering.
• The format may be modified according to the
client’s physical status such as one focused on
musculoskeletal data for orthopedic clients.
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33. c. Validating Data:
• Data verification is the process through which data
are validated as being complete and accurate. Once
the nurse completes the initial data collection, the
data are reviewed for inconsistencies or omissions.
• The information gathered during the assessment
phase must be complete, factual and accurate
because the nursing diagnosis and interventions
are based on this information.
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34. Contd……
Validating data helps the nurse complete these tasks:
• ensure that assessment information is complete,
• ensure that objective and related subjective data
agree,
• obtain additional information that may have been
overlooked and
• Differentiate between cues and inferences (cues are
subjective and objective date that can be directly
observed by the nurse; that is, what client says and
what the nurse can see, hear, smell or measure.
Inferences are the nurse’s interpretation or
conclusions made based on cues).
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35. • For example, if a client is confused or unable to
communicate, or if two sources provide conflicting
data, it is necessary for the nurse to seek further
information or clarification.
• Data verification is done by examining the congruence
between subjective and objective data.
• For example, a client might exhibit nonverbal
expressions of pain (e.g., guarding a part of the body,
facial grimacing) but verbally deny feeling pain.
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36. d. Documenting data:
• Assessed data should be recorded and some should
be reported immediatey.
• Accurate documentation is essential and should
include all data collected about the client health
status.
• Data are recorded in a factual manner and not
interpreted by the nurse.
• Documentation of data is essential to communicate
the information of the patient to the other related
health care team members and ensures for the
delivery of continuous quality of care.
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37. Copyright 2008 by Pearson Education, Inc.
The Nursing Process
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