AssessmentAssessmentAubrey 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. TrueB. False

Answer

Answer: B. FalseA 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 assessmentB. Focused assessmentC. Emergency assessmentD. Time-lapsed assessment

Answer

Answer: B. Focused assessmentRationale: 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 manHeight: 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. TrueB. False

Answer

Answer: B. FalseA 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. TrueB. False

AnswerAnswer: A. TrueMost 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 phaseB. IntroductionC. Working phaseD. Termination

Answer

Answer: C. Working phaseRationale: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 24-hour 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 self-care, 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