Assessment – First Step in the Nursing Process
April 22, 2008 · 26 Comments
- 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
4 Types of Assessment:
a. Initial assessment – assessment performed within a specified time on admission
Ex: nursing admission assessment
b. 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
c. 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.
d. time-lapsed assessment – reassessment of client’s functional health pattern done several months after initial assessment to compare the clients current status to baseline data previously obtained.
- Collection of data
- Validation of data
- Organization of data
- Analyzing of data
- Recording/documentation of data
Assessment = Observation of the patient + Interview of patient, family & SO + examination of the patient + Review of medical record
I. 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:
- 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
- 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:
- 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
- Observation – use to gather data by using the 5 senses and instruments.
- systematic data collection to detect health problems using unit of measurements, physical examination techniques (IPPA), interpretation of laboratory results.
- should be conducted systematically:
- Cephalocaudal approach – head-to-toe assessment
- Body System approach – examine all the body system
- Review of System approach – examine only particular area affected
Source of data:
- Primary source – data directly gathered from the client using interview and physical examination.
- 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.
II. Validation of Data – the act of “double-checking” or verifying data to confirm that it is accurate and complete.
Purposes of data validation:
- ensure that data collection is complete
- ensure that objective and subjective data agree
- obtain additional data that may have been overlooked
- avoid jumping to conclusion
- 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
III. Organization of Data – uses a written or computerized format that organizes assessment data systematically.
- Maslow’s basic needs
- Body System Model
- Gordon’s Functional Health Patterns:
- Health perception-health management pattern.
- Nutritional-metabolic pattern
- Elimination pattern
- Activity-exercise pattern
- Sleep-rest pattern
- Cognitive-perceptual pattern
- Self-perception-concept pattern
- Role-relationship pattern
- Sexuality-reproductive pattern
- Coping-stress tolerance pattern
- Value-belief pattern
IV. 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
V. 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.