Assessment
Aubrey Y. Go, RN, MD
Assessment
•
•
•
•
•
systematic
continuous
collection
validation
communication
4 Types of
Nursing Assessments
•
•
•
•
Comprehensive Initial
Focused
Emergency
Time-lapsed
Question
Tell whether the following statement is true or
false.
A nursing assessment duplicates a medical
assessment by focusing on the patient’s
responses to the health problem.
A. True
B. False
Answer
Answer: B. False
A nursing assessment does not duplicate a
medical assessment, rather it focuses on the
patient’s responses to the health problem.
The Primary Source of Information Is the Patient
Question
Which one of the following assessments would be
performed on a patient to gather data about his
previously diagnosed liver cancer?
A. Initial assessment
B. Focused assessment
C. Emergency assessment
D. Time-lapsed assessment
Answer
Answer: B. Focused assessment
Rationale:
In a focused assessment the nurse gathers data about a
condition that has already been diagnosed.
An initial assessment is performed shortly after the patient is
admitted to a healthcare agency or service.
When a physiologic or psychological crisis presents, the nurse
performs an emergency assessment.
A time-lapsed assessment compares a patient’s current status
to baseline data obtained earlier.
Comprehensive Initial Assessment
• performed shortly after admittance to hospital
• to establish a complete database for problem
identification and care planning
• to collect data on all aspects of patient’s
health
Focused Assessment
• may be performed during initial assessment or as
routine ongoing data collection
• to gather data about a specific problem already
identified
• to identify new or overlooked problems
• to collect data about the specific problem
Emergency Assessment
• done when presented physiologic or
psychological crisis
• to identify life-threatening problems
• to gather data about the life-threatening
problem
Time-Lapsed Assessment
• to compare a patient’s current status to
baseline data obtained earlier
• to reassess health status and make necessary
revisions in plan of care
• to collect data about current health status of
patient
Establishing Assessment Priorities
• Health orientation
• Developmental stage
• Need for nursing
* Practical Considerations
Medical vs. Nursing Assessments
• Medical assessments
– target data pointing to pathologic conditions
• Nursing assessments
– focus on the patient’s response to health
problems
Data
•
•
•
•
•
•
pertinent patient info
comprehensive and effective plan of care
vital step in nursing process
complete
accurate and factual
relevant
Sources of Data
•
•
•
•
•
•
nursing history
physical examination
patient’s family, significant others
patient record
healthcare professionals
nursing and other healthcare
literature
Objective Data vs. Subjective Data
• Objective data
– observable and measurable data
– can be seen, heard, or felt by someone other than the
person experiencing them
– e.g., elevated temperature, skin moisture, vomiting
Objective Data vs. Subjective Data
• Subjective data
– information perceived only by the affected person
– e.g., pain experience, feeling dizzy, feeling anxious
Objective
• 32-year-old man
Height: 5′8″
Weight:
9/18/07—224 lb
2/4/08—202 lb
• Posterior, left midcalf is
warm and red.
• Patient observed fidgeting
with bed covers; facial
features are tightly drawn.
Subjective
• “I'm beginning to feel better
about myself now that I'm
losing weight and I seem to
have more energy.”
• “My leg hurts when I walk.”
• “I'm so afraid of what they
might find when they cut
me open tomorrow.”
Question
Tell whether the following statement is true or
false.
A patient rates his pain as a “7” on a pain
rating scale. This rating is considered to be
objective data.
A. True
B. False
Answer
Answer: B. False
A patient rates his pain as a “7” on a pain
rating scale. This rating is considered to be
subjective data.
CHARACTERISTICS OF DATA
Purposeful
• the nurse identifies the purpose of the nursing
assessment
• nature and amount of data collected depend
on the circumstances of the patient situation
Complete
• identify all the patient data needed to
understand a patient health problem and
develop a plan of care to maximize health and
well-being
Factual and Accurate
•
•
•
•
•
verify
validate
reliable source of data
personal bias and stereotyping
describe observed behavior rather than to
interpret the behavior
Relevant
• determine what type of data and how much
data to collect for each patient
• aim is to record concisely all pertinent data.
• experience teaches nurses what data are
needed in specific cases.
Sources of Data
•
•
•
•
•
•
Patient
Family and significant others
Patient record
Other healthcare professionals
Laboratory and Other Diagnostic Studies
Nursing and other healthcare literature
Question
Tell whether the following statement is true or false.
Most healthcare institutions establish a minimum data set
that specifies the information that must be collected from
every patient and uses a structured assessment form to
organize or cluster these data.
A. True
B. False
Answer
Answer: A. True
Most healthcare institutions establish a
minimum data set that specifies the
information that must be collected from every
patient and uses a structured assessment
form to organize or cluster these data.
METHODS OF ASSESSMENT
Observation
• determines the patient’s current responses (physical
and emotional)
• determines the patient’s current ability to manage
care
• determines the immediate environment and its
safety
• determines the larger environment (hospital or
community)
Nursing History
• Profile: name, age, sex, marital status, religion, occupation,
education
• Reason for seeking healthcare
• Normal health habits and patterns and related needs for
nursing assistance
• Cultural considerations in relation to diet, decision-making,
and activities
• Current state of health, functioning of body systems, degree
of pain, and past medical and surgical history
Nursing History
• Current medications, allergies, and record of immunizations
and exposure to communicable diseases
• Perception of health status and the meaning the patient
attributes to health and illness, and characteristic response or
coping patterns
• Developmental history, family history, environmental history,
and psychosocial history
Nursing History
• Patient's and family's expectations of
nursing and of the healthcare team
• Patient's and family's educational needs and
ability and willingness to learn
• Patient's and family's ability and willingness
to participate in the plan of care
• Whether or not an advance directive exists,
or if the patient wants help to prepare an
advance directive
• Patient's personal resources (strengths) and
deficits
• Patient's potential for injury
Four Phases of a Nursing Interview
•
•
•
•
Preparatory phase
Introduction
Working phase
Termination
Question
In which of the following phases of the nursing
interview does the nurse gather all the information
needed to form the subjective database?
A. Preparatory phase
B. Introduction
C. Working phase
D. Termination
Answer
Answer: C. Working phase
Rationale:
The patient database is obtained in the working phase.
In the preparatory phase, the nurse prepares the patient and
the environment for the interview.
The introduction sets the tone for the remainder of the
interview.
The termination is the conclusion of the interview.
Interview Techniques
•
•
•
•
Focus on the patient during the interview
Listen to the patient attentively
Ask about patient’s main problem first
Pose questions and comments in
appropriate manner
• Avoid comments and questions that
impede communication
• Use silence and touch appropriately
Type of Questions Used in
Interviews
• Closed questions—elicit specific
information
• Open-ended questions—allow
the patient to verbalize freely
Type of Questions Used in
Interviews
• Reflective questions—encourage
patient to elaborate on thoughts
and feelings
• Direct questions—validate or
clarify information
Purpose of a Nursing Physical
Assessment
• Appraisal of health status
• Identification of health problems
• Establishment of a database for
nursing intervention
Physical Assessment
• examination of the patient for
objective data
• normally follows the nursing
history and interview
Physical Assessment
• may verify data gathered during
the history or yield new data
• focuses primarily on the patient's
functional abilities
Diagnostic and Laboratory Data
• may support data gathered from history and
physical assessment
• may identify new and incidental findings
• collection of specimen should be accurate
• may be used for evaluation
MODELS FOR ORGANIZING OR
CLUSTERING DATA
Human Needs (Maslow)
Functional Health Patterns
(Gordon)
• Health Perception/Health Management:
– Perception of general health status and well-being.
Adherence to preventive health practices
• Nutritional–Metabolic:
– Patterns of food and fluid intake, fluid and
electrolyte balance, general ability to heal
• Elimination:
– Patterns of excretory function (bowel, bladder,
skin) and client's perception
Gordon’s … cont’d
• Activity/Exercise:
- Pattern of exercise, activity, leisure, recreation, and ADL;
factors that interfere with desire to expected individual
pattern
• Cognitive–Perceptual:
- Adequacy of sensory modes, such as vision, hearing, taste,
touch, smell, pain perception, cognitive functional abilities
Gordon’s … cont’d
• Sleep/Rest:
- Patterns of sleep and rest-relaxation periods during 24hour day, as well as quality and quantity
• Self Perception/Self Concept:
- Attitudes about self, perception of abilities, body image,
identity, general sense of worth and emotional patterns
Gordon’s … cont’d
• Role/Relationship:
- Perception of major roles and responsibilities in current
life situation
• Sexuality and Reproductive:
- Perceived satisfaction or dissatisfaction with sexuality.
Reproductive state and pattern
Gordon’s … cont’d
• Coping/Stress Tolerance:
- General coping pattern, stress tolerance, support systems,
and perceived ability to control and manage situations
• Value-Belief:
- Values, goals, or beliefs that guide choices or decisions
Human Response Patterns (Unitary
Person)
• Exchanging: Nutritional status, temperature, elimination,
oxygenation, circulation, fluid balance, skin, and mucous
membranes, risk for injury
• Communicating: Ability to express thoughts verbally;
orientation, speech impairments, language barriers
Human Response Patterns… cont’d
• Relating: Establishing bonds, social
interaction, support systems, role
performance (including parenting,
occupation, and sexual role)
• Valuing: Religious and cultural preference
and practices, relationship with deity,
perception of suffering; acceptance of illness
Human Response Patterns… cont’d
• Choosing: Ability to accept help and make
decisions, adjustment to health status,
desire for independence/dependence,
denial of problem, adherence to therapies
• Moving: Activity tolerance, ability for selfcare, sleep patterns, diversional activities,
disability history, safety needs,
breastfeeding
Human Response Patterns… cont’d
• Perceiving: Body image, self-esteem, ability to use all five
senses, amount of hopefulness, perception of ability to
control current situation
• Knowing: Knowledge about current illness or therapies;
previous illnesses; risk factors, expectations of therapy,
cognitive abilities; readiness to learn, orientation, memory
• Feeling: Pain, grieving, risk for violence, anxiety level,
emotional integrity
Body System Model
•
•
•
•
•
•
•
Neurologic
Cardiovascular
Respiratory
Gastrointestinal
Musculoskeletal
Genitourinary
Psychosocial
Collaborating Members
of the Healthcare Team
Psychosocial Assessment
• Appearance
– Age, sex, race, body build, posture, eye contact, dress, grooming,
manner, attentiveness to assessor, distinguishing features, prominent
physical abnormalities, emotional or facial expression, alertness
• Behaviour
– Attitude towards situation and assessor – Is the individual
friendly,hostile, guarded, cooperative, uncommunicative, seductive?
• Sensorium
– Level of consciousness, degree of awareness of surroundings
• Mental Function
– Thought Content: suicidal ideation, homicidal ideation, depressive
cognitions, obsessions, ruminations, phobias, ideas of reference,
paranoid, ideation, magical ideation, delusions, overvalued ideas
– Thought process: attention (also relevant in
cognition), associations, coherence, logic, stream,
perseveration, neologism, thought blocking; can be
useful to document a verbatim example of
disorganised speech
– Perception: hallucinations, illusions,
depersonalisation, derealisation, déjà vu
– Intellect: Global impression (average, above average,
below average); level of educational achievement
– Cognition: orientation (time, place, person), memory,
concentration, attention
– Insight: awareness of illness
Problems Related to Data Collection
• Inappropriate organization of the database
• Omission of pertinent data
• Inclusion of irrelevant or duplicate data, erroneous or
misinterpreted data
• Failure to establish rapport and partnership
• Recording an interpretation of data rather than observed
behavior
• Failure to update the database
When to Verify Data
• When there is a discrepancy
between what the person is
saying and what the nurse is
observing
• When the data lack objectivity
Validating Inferences
• Performing a physical examination using
proper equipment and procedure
• Using clarifying statements
• Sharing inferences with other team members
• Checking findings with research reports
Documentation of Data
• Enter initial database into computer or record in ink on
designated forms the same day patient is admitted
• Summarize objective and subjective data in concise,
comprehensive, and easily retrievable manner
Documentation of Data
• Use good grammar and standard medical
abbreviations
• Whenever possible, use patient’s own words
• Avoid non-specific terms subject to
individual interpretation or definition