Chapter 11
Assessment
Assessment
 Assessment is the first step in the
nursing process and includes systematic
collection, verification, organization,
interpretation, and documentation of data
for use by health care professionals.
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Purpose of Assessment
 To determine the client’s functional
abilities and the absence or presence of
dysfunction.
 Identification of the client’s skills, abilities,
and behaviors available to promote
treatment and recovery.
 Establish a therapeutic relationship.
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Types of Assessment
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Comprehensive Assessment
Focused Assessment
Ongoing Assessment
Emergency Assessment
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Comprehensive Assessment
 Usually completed upon admission.
 Provides baseline data:
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Physical and psychosocial aspects
Client’s perception of health
Presence of health risk factors
Client’s coping patterns
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Focused Assessment
 Limited in scope in order to focus on a
particular need or health problem.
 Less detailed.
 Health care agencies in which short stays
are anticipated.
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Ongoing Assessment
 Systematic monitoring and observation
related to specific problems.
 Database is broadened or confirmed.
 Determine client’s response to nursing
interventions.
 Identify any emerging problems.
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Ongoing Assessment
 Home care nurses using ongoing
assessments must direct the client to
provide information relevant to the
current problem.
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Emergency Assessment
 A rapid assessment of clients
experiencing life-threatening problems or
crises.
 Problems can be of physiological and/or
psychological and sociological nature.
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Data Collection
 Uses cognitive, interpersonal, and
technical skills to elicit appropriate
information.
 A variety of sources and methods are
used in compiling a comprehensive
database.
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Types of Data
 Subjective
• Client’s perception, feelings, opinions,
concerns
• Also referred to as symptoms
• Cannot be readily observed by others
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Types of Data
 Objective
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Observable, measurable (quantitative)
Also referred to as signs
Standard assessment techniques
Laboratory and diagnostic testing
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Sources of Data
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Client, family, significant others
Medical records
Other health care professionals
Diagnostic tests
Rounds
Literature sources
Nursing knowledge
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Methods of Data Collection
 Observation
• General appearance and behavior of the
client
• Nonverbal cues may indicate pain, anxiety,
anger or physical changes.
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Methods of Data Collection
 Interview
• Collection of information about the client’s
health history and current status in order to
determine client’s health needs.
• Effective interviewing depends on the
nurse’s knowledge and ability to skillfully
elicit information from the client.
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Interview
 Preparation for the Interview
• Review of the client’s medical records
• Communication with other health team
members
• Research of the presenting medical
diagnosis
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Interview Preparation
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Assure adequate lighting.
Maintain comfortable room temperature.
Control for noise and distractions.
Maintain client privacy.
Establish time guidelines for interview.
Promote client comfort.
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Interview Stages
 Introduction
 Working
 Closure
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Interview Stages
 Introduction Stage
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Beginning of a nurse-client relationship.
Introductions are made.
Establishes rapport.
Defines roles.
Explains purpose and use of data.
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Interview Stages
 Working Stage
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Focuses on data collection.
Questions move from general to specific.
Closed-ended questions yield brief answers.
Open-ended questions encourage the client
to elaborate about a particular concern.
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Interview Stages
 Closure Stage
• Nurse summarizes data.
• Asks for validation.
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Health History
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Demographic Information
Reason for Seeking Health Care
Perception of Health Status
Previous Illnesses, Hospitalizations,
Surgeries
 Client/Family Medical History
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Health History
 Immunizations/Exposure to
Communicable Disease
 Allergies
 Current Medications
 Developmental Level
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Health History
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Psychosocial History
Value and Belief System
Activities of Daily Living
Review of Systems
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Physical Examination
 Baseline Data
 Assessment Techniques
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Inspection
Palpation
Percussion
Auscultation
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Physical Examination
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Laboratory and Diagnostic Data
 Objective data that serve as defining
characteristics for various altered health
states.
 Effectiveness of interventions and
progress toward health restoration are
often monitored through test data.
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Data Verification
 The process by which data are validated
as complete and accurate.
 Data are reviewed for inconsistencies or
omissions.
 Subjective and objective data are
examined for congruence.
 Findings should be compared with
norms.
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Data Organization
 Data clustering is organization of the
information in order to identify strengths
and weaknesses.
 How data is clustered depends on the
assessment model used.
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Data Organization
 Assessment Models
• Nursing Models
• Non-Nursing Models
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Assessment Models
 Nursing Models
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Gordon’s Functional Health Patterns
Human Response Pattern
Theory of Self-care
Roy Adaptation Model
Leininger Sunrise Model
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Assessment Models
 Non-Nursing Assessment Models
• Body Systems Model
• Hierarchy of Needs
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Data Interpretation and
Documentation
 Data clustering facilitates recognition of
patterns and determination of further data
that is needed.
 Data interpretation is necessary for
identification of nursing diagnoses.
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Data Interpretation and
Documentation
 Types of Assessment Formats
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Open-Ended Formats
Checklist Formats
Combination Formats
Specialty Formats
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Sample Assessment Forms
 Click one of the links below to view a
sample assessment form
• Application: assessment in the industrial
clinic
• Sample assessment form: open-ended
• Sample assessment form: combination
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Specialty Formats
 The MDS Medicare Prospective Payment
Assessment Form (MPAF)
• Developed by the Health Care Financing
Administration (currently CMS).
• Used in all skilled and long-term care
facilities that are funded by CMS.
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