Chapter 16
Nursing Assessment
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Five-Step Nursing Process
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
2
Nursing Process




The nursing process is a variation of scientific
reasoning.
Practicing the five steps of the nursing process allows
you to be organized and to conduct your practice in a
systematic way.
You learn to make inferences about the meaning of a
patient’s response to a health problem or generalize
about the patient’s functional state of health.
Through assessment, a pattern begins to form.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
3
Critical Thinking Approach
to Assessment


Assessment involves collecting information
from the patient and from secondary sources
(e.g., family members), along with interpreting
and validating the information to form a
complete database.
Two stages of assessment:


Collection and verification of data
Analysis of data
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
4
Case Study


Ms. Carla Thompkins is being admitted to the
medical-surgical unit as a postop patient. Ms.
Thompkins, a 52-year-old schoolteacher, is
recovering from a below-the-knee amputation (BKA)
secondary to complications of type 2 diabetes.
Ms. Thompkins is admitted to the unit not only so her
recovery from the BKA may be monitored, but also
because Ms. Thompkins is going to receive
preliminary occupational and physical therapy to help
her adapt to the amputation.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
5
Database



The purpose of assessment is to establish a
database about the patient’s perceived
needs, health problems, and responses to
these problems.
In addition, the data reveal related goals,
experiences, health practices, values, and
expectations about the health care system.
Critical thinking skills help you to synthesize
relevant information and use it in a purposeful
way.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
6
Data Collection

Sources of data







Patient (interview, observation, physical
examination)—the best source of information
Family and significant others (obtain patient’s
agreement first)
Health care team
Medical records
Scientific literature
Nurse’s experience
Subjective vs. objective data
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
7
Cues and Inferences
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
8
Comprehensive Assessment
Approaches

Use of a structured database format, based
on an accepted theoretical framework or
practice standard



Example: Gordon’s model of functional health
patterns
Problem-oriented approach
Assessment moves from general to specific.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
9
Process of Assessment





Collect data.
Cluster cues, make inferences, and identify
patterns and problem areas.
Critically anticipate.
Be sure to have supporting cues before
making an inference.
Knowing how to probe and frame questions is
a skill that grows with experience.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
10
Methods of Data Collection

Patient-centered interview = An organized
conversation with the patient




Set the stage (preparation, environment, greeting).
Set an agenda/gather information about patient’s
concerns.
Collect the assessment or nursing health history;
assure the patient of confidentiality.
Terminate the interview (cue the end).
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
11
Interview Techniques
Open-ended vs. closed-ended questions
 Back-channeling
 Probing
------------------------------------------ Because a patient’s report includes subjective
information, validate data from the interview
later with objective data.
 Obtain information (as appropriate) about a
patient’s physical, developmental, emotional,
intellectual, social, and spiritual dimensions.

Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
12
Case Study (cont’d)

During the assessment, Ms. Thompkins
complains of pain at the incision site.

Ms. Thompkins’ report of pain is an example of
what type of data?
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
13
Cultural Considerations



To conduct an accurate and complete
assessment, you need to consider a patient’s
cultural background.
When cultural differences exist between you
and a patient, respect the unfamiliar and be
sensitive to a patient’s uniqueness.
If you are unsure about what a patient is
saying, ask for clarification to prevent making
the wrong diagnostic conclusion.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
14
Quick Quiz!
1. A patient is admitted to the hospital with
shortness of breath. As the nurse assesses this
patient, the nurse is using the process of
A. Evaluation.
B. Data collection.
C. Problem identification.
D. Testing a hypothesis.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
15
Nursing Health History
Biographical
information
Reason for seeking
health care
Health history
Patient expectations
Environmental history
Spiritual health
Psychosocial history
Review of systems
Present illness or
health concerns
Family history
Documentation of findings
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
16
Next Assessment Steps




Physical examination = An investigation of
the body to determine its state of health
Observation of patient behavior (verbal vs.
nonverbal)
Diagnostic and laboratory data
Interpreting and validating assessment data.
Validation of assessment data consists of
comparison of data with another source to
determine accuracy of the data.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
17
Case Study (cont’d)
Which of the following statements or questions made
by Yolanda to Ms. Thompkins addresses the nature
of Ms. Thompkins’ pain?
(Select all that apply.)
A. “Describe your pain to me.”
B. “Is the pain worse in the morning or in the
evening?”
C. “Place your hand over the area that is
uncomfortable.”
D. “Rate your pain on a scale of 0 to 10.”

Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
18
Data Documentation
The last component of a complete
assessment
Legal and professional
responsibility
Requires accurate and approved
terminology and abbreviations
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
19
Quick Quiz!
2. The nursing process organizes your
approach to delivering nursing care. To
provide care to your patients, you will need to
incorporate nursing process and
A. Decision making.
B. Problem solving.
C. Interview process.
D. Intellectual standards.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
20
Case Study (cont’d)

True or False: Yolanda knows that the best
source of information regarding Ms.
Thompkins’ care is the surgeon.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
21
Concept Mapping
A visual representation that allows
nurses to graphically illustrate the
connections between a patient’s
health problems
Allows nurses to obtain a holistic
perspective of health care needs
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
22