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Assessment – First Step in the Nursing Process

  • It is systematic and continuous collection, validation and communication of client data as compared to what is standard/norm.
  • It includes the client’s perceived needs, health problems, related experiences, health practices, values and lifestyles.

Purpose

To establish a data base (all the information about the client):

  • nursing health history
  • physical assessment
  • the physician’s history & physical examination
  • results of laboratory & diagnostic tests material from other health personnel

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FOUR Types of Assessment

  1. Initial assessment – assessment performed within a specified time on admission
    • Ex: nursing admission assessment
  2. Problem-focused assessment – use to determine status of a specific problem identified in an earlier assessment
    • Ex: problem on urination-assess on fluid intake & urine output hourly
  3. Emergency assessment – rapid assessment done during any physiologic/physiologic crisis of the client to identify life threatening problems.
    • Ex: assessment of a client’s airway, breathing status & circulation after a cardiac arrest.
  4. Time-lapsed assessment – reassessment of client’s functional health pattern done several months after initial assessment to compare the client’s current status to baseline data previously obtained.

Activities 

  1. Collection of data
  2. Validation of data
  3. Organization of data
  4. Analyzing of data
  5. Recording/documentation of data

Assessment 

  • Observation of the patient + Interview of patient, family & SO + examination of the patient + Review of medical record

Collection of data 

  • gathering of information about the client
  • includes physical, psychological, emotion, socio-cultural, spiritual factors that may affect client’s health status
  • includes past health history of client (allergies, past surgeries, chronic diseases, use of folk healing methods)
  • includes current/present problems of client (pain, nausea, sleep pattern, religious practices, meds or treatment the client is taking now)

Types of Data 

  1. Subjective data 
    • also referred to as Symptom/Covert data
    • Information from the client’s point of view or are described by the person experiencing it.
    • Information supplied by family members, significant others; other health professionals are considered subjective data.
    • Example: pain, dizziness, ringing of ears/Tinnitus
  2. Objective data
    • also referred to as Sign/Overt data
    • Those that can be detected observed or measured/tested using accepted standard or norm.
    • Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin

Methods of Data Collection 

  1. Interview 
    • A planned, purposeful conversation/communication with the client to get information, identify problems, evaluate change, to teach, or to provide support or counseling.
    • it is used while taking the nursing history of a client
  2. Observation 
    • Use to gather data by using the 5 senses and instruments.
  3. Examination 
    • Systematic data collection to detect health problems using unit of measurements, physical examination techniques (IPPA), interpretation of laboratory results.
    • should be conducted systematically:
    1. Cephalocaudal approach – head-to-toe assessment
    2. Body System approach – examine all the body system
    3. Review of System approach – examine only particular area affected

Source of data 

  1. Primary source – data directly gathered from the client using interview and physical examination.
  2. Secondary source – data gathered from client’s family members, significant others, client’s medical records/chart, other members of health team, and related care literature/journals.
    • In the Assessment Phase, obtain a Nursing Health History – a structured interview designed to collect specific data and to obtain a detailed health record of a client.

Components of a Nursing Health History: 

  • Biographic data – name, address, age, sex, martial status, occupation, religion.
  • Reason for visit/Chief complaint – primary reason why client seek consultation or hospitalization.
  • History of present Illness – includes: usual health status, chronological story, family history, disability assessment.
  • Past Health History – includes all previous immunizations, experiences with illness.
  • Family History – reveals risk factors for certain disease diseases (Diabetes, hypertension, cancer, mental illness).
  • Review of systems – review of all health problems by body systems
  • Lifestyle – include personal habits, diets, sleep or rest patterns, activities of daily living, recreation or hobbies.
  • Social data – include family relationships, ethnic and educational background, economic status, home and neighborhood conditions.
  • Psychological data – information about the client’s emotional state.
  • Pattern of health care – includes all health care resources: hospitals, clinics, health centers, family doctors.

Validation of Data 

  • The act of “double-checking” or verifying data to confirm that it is accurate and complete.

Purposes of data validation 

  1. ensure that data collection is complete
  2. ensure that objective and subjective data agree
  3. obtain additional data that may have been overlooked
  4. avoid jumping to conclusion
  5. differentiate cues and inferences

Cues 

  • Subjective or objective data observed by the nurse; it is what the client says, or what the nurse can see, hear, feel, smell or measure.

Inferences

  • The nurse interpretation or conclusion based on the cues.
  • Example:
    • Red swollen wound = infected wound
    • Dry skin = dehydrated

Organization of Data 

Uses a written or computerized format that organizes assessment data systematically.

  1. Maslow’s basic needs
  2. Body System Model
  3. Gordon’s Functional Health Patterns:

Gordon’s Functional Health Patterns 

  1. Health perception-health management pattern.
  2. Nutritional-metabolic pattern
  3. Elimination pattern
  4. Activity-exercise pattern
  5. Sleep-rest pattern
  6. Cognitive-perceptual pattern
  7. Self-perception-concept pattern
  8. Role-relationship pattern
  9. Sexuality-reproductive pattern
  10. Coping-stress tolerance pattern
  11. Value-belief pattern

Analyze data 

  • Compare data against standard and identify significant cues. Standard/norm are generally accepted measurements, model, pattern:
    • Ex: Normal vital signs, standard Weight and Height, normal laboratory/diagnostic values, normal growth and development pattern

Communicate/Record/Document Data 

  • nurse records all data collected about the client’s health status
  • data are recorded in a factual manner not as interpreted by the nurse
  • Record subjective data in client’s word; restating in other words what client says might change its original meaning.
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