Assessment in nursing process
· Collect, organize, validate data
· Obtain information from charts, client, family.
· Data gathering
· Establish information about person's response to health concerns and ability to manage
Definition of Assessment
The assessment is the deliberate and systematic collection of data to determine a clients current and past health status and to determine the client present and past coping pattern
(Car Penito 2000)
You can perform assessment to gather information needed to make and accurate judgment about a patients current condition.
As one begin a patient assessment think critically about what to assess for that specific patient.
Eg: emergency department nurse uses the ABC approach, surgical nurse focuses on the patients symptoms following surgery, healing response and complications.
Types of data
There are two primary sources of data
1. Subjective data
2. Objective data
Patients verbal descriptions of their health problems. Only patients provide subjective data.
Eg: Patient s report of incision pain and his expression of concern about whether the pain means that he will not be able to go home as soon; as patient hoped subjective findings.
Subjective data usually include feelings, perceptions, and self report of symptoms. Only patients provide subjective data relevant to their health condition.
Observations or measurements of patients health status. Inspecting the condition of a surgical incision or wound, describing an observed behavior and measuring blood pressure are examples of objective data.
The measurement of objective data is based on an accepted standards
Fahrenheit/Celsius on a thermometer
Inches/centimeters on a measuring tape
Behavior characteristics (anxiety/ fear)
TYPES OF DATA
I am worried about surgery.
Patient is rest less.
I can not sleep well.
Temperature 100* F
I can not work that far.
Old surgical scar.
I had not had a bowel movement for three days.
Hb% 5 gram
I can not eat properly.
High blood pressure
Pulse rate – 120 beats/ min
Sources of data
As a nurse you obtain data from a variety of sources that provide information about the patients
· Current level of wellness and functional status
· Anticipated prognosis
· Risk factors
· Health practices and goals
· Responses to previous treatment
· Patterns of health and illness
Sources of data
2. Family and significant others
3. Health care team
4. Medical records
5. Other records and scientific literature
6. Nurse's Experience
Usually best source of information
Who is conscious alert and able to answer questions correctly provide the most accurate information about
· their health care needs
· lifestyle patterns
· present and past illnesses
· perceptions of symptoms
· responses to treatment
· changes in activities of daily living
2. Family and significant others
Family members and significant others are prima sources of information
· for infants or children
· Critically ill adults
· Patient who are mentally handicapped
They even confirm findings that a patient provides (whether he takes medications regularly at home or how well he sleeps or eats).
They make important observations about patients needs that can affect the way care is delivered.
3. Health care team
Frequently we communicate with other health care team members in gathering information about patients. In the acute care setting the change of shift report is how nurse from one shift communicate information to nurses on the next shift.
When nurses, physicians, physical therapists, social workers, or other staff consult on a patients condition they share information about how the patient is interacting within the health care environment, reactions to treatment and result of therapies.
4. Medical Records
The medical record is source for the patients medical history, laboratory and test results, current physical findings, and the primary health care providers treatment plan.
The record is a valuable tool for checking the consistency and similarities of your personal observations
Information in a patients record is confidential. Each health care agency has policies governing the patients health information.
5. Other records and the scientific literature
Educational, military and employment records sometimes contain significant health care
information (immunizations). If a patient received services at a community health or different hospital we need written permission from the patient or guardian to access the records.
6. Scientific literature
Reviewing nursing, medical and pharmacological literature about a patients illness completes your assessment database.
· This review increases our knowledge about
· patients diagnosed problems
· expected symptoms
· prognosis and
· established standards of therapeutic practice
7. Nurse's experience
Through clinical experience a nurse
· observes other patients,
· recognizes clinical changes
· learns the types of questions to ask
· choosing only the questions that will give the most useful information
· Practical experience and the opportunity to make clinical decisions strengthen our critical thinking
Methods of data collection
1. Patient centered interviews
2. The nursing health history
3. Physical examination
4. Observation of patient behavior and
5. Results of laboratory and diagnostic tests
I. Patient centered interviews
It is an approach for obtaining from patients the data that are needed to foster a caring nurse patient relationship, adherence to interventions, and treatment effectiveness.
A successful interview requires preparation. Collect available information about the patient before starting the interview
An initial patient centered interview involves
· Setting the stage
· Gathering information about the patients chief concerns or problems and setting an agenda
· Collecting the assessment or a nursing health history
· Terminating the interview
Open ended questions
Eg: tell me how are you feeling?
Closed ended questions
Eg: who helps you at home?
2. Nursing Health History
· We gather a nursing health history during either your initial or an early contact with a patient.
3. Physical Examination
A physical examination is an investigation of the body to determine its state of health. The examination involves use of the techniques of inspection, palpation, percussion, auscultation and smell.
A complete examination includes a patients height, weight, vital signs, and a head to toe examination of all body systems.
Examples of physical assessment findings
· Vital Signs: B.P. 160/90(hypertension),
· respirations: 28(tachypnea), pulse:96
· Height and Weight: 5ft., 10in.,77kgs.
· Skin: Dryness, scratches, jaundice.
· Eyes: Scleral icterus
· Thorax: Spider angiomas
· Breast: Gynecomastia
· Abdomen: Distention. prominent veins. girth: 715cm, liver enlargement.
4. Observation of patient behavior
· Throughout a patient centered interview and physical examination it is important for you to closely observe a patients verbal and nonverbal behaviors.
· You learn to determine if data obtained by observation matches what the patient communicates verbally.
· Observation should include physical, developmental, psychological and social aspects of everyday living.
· Eg: if a patient expresses no concern about an upcoming diagnostic test but shows poor eye contact, shakiness and restlessness, all suggesting anxiety; verbal and non verbal data conflict.
5. Diagnostic and laboratory data
The results of diagnostic and laboratory test provide further explanation of alterations or problems identified during the nursing health history and physical examination
Eg: during the history patient reports having a bad cold for 6 days and at present has a productive cough with brown sputum and mild shortness of breath. On physical examination you notice an elevated temperature, increased respirations and decreased breath sounds in the right lower lobe. CBC review shows elevated WBC. X ray film shows right lower lobe infiltrate.
Physician diagnosis: pneumonia
Nursing diagnosis: impaired gas exchange
Whichever clinical situation you face, assessment involves the continuous interpretation of information.
The successful interpretation and validation of assessment data ensure that you have collected a complete database for your patient.
When interpreting assessment information critically, you determine the presence of abnormal findings, recognize that further observations are needed to clarify information, and begin to identify the patients health problems.
Data cluster: cluster is a set of signs or symptoms that you group together in a logical way.
· Patient uncomfortable: remains in bed
· Limits turning
· Grimaces when moving
· Mobility limited: limits turning
Indicates impaired mobility