Assessment
Assessment in nursing process
·
Introduction
·
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)
Data
collection
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
Subjective 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.
Objective
data
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
|
Subjective data
|
Objective data
|
|
Example:
|
Example:
|
|
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
|
|
|
Albuminuria
|
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
1. Patient
2. Family and significant others
3. Health care team
4. Medical records
5. Other records and scientific literature
6. Nurse's Experience
1. Patient
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
·
Disoriented
·
Unconscious
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
Records
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
·
treatment
·
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
Interview
techniques
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
Data
interpretation
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.
Eg:
·
Patient
uncomfortable: remains in bed
·
Limits
turning
·
Grimaces
when moving
·
Mobility
limited: limits turning
Indicates
impaired mobility
COMMENTS