nursingassessment-220411150937.pnursingassessment-220411150937.pdfdf
- 2. Nursing Assessment: Assessment is the first step of nursing process. Assessing is the systematic and continuous collection, organization, validation and documentation of data. This includes data about persons physical and psychological status or study of the patient as a whole to identify his strengths and weakness and his needs and problems Nursing assessment does not focus upon disease as do medical assessment. It is based on a board scientific knowledge, keen observation and purposeful listening. 2
- 3. Assessing is the systematic and continuous collection, organization, validation and documentation of data. Potter and Perry( 2006) Assessment is the deliberate and systematic collection of data to determine a clients current and past health status and to determine the clients present and past coping patterns Carpenito 2000 Assessment is the systematic and continuous collection, validation and communication of patient data. Carol Taylor 3
- 4. Contd.. It starts with the admission of the patient and continues while the patient is under the care of the nurse Continuous assessment helps to modify the nursing care plan according to the changing needs of the patient. There are four different types of assessment: A) Initial / comprehensive assessment B) Problem-Focused assessment C) Emergency assessment D) Time-lapsed reassessment 4
- 5. 1. Initial / comprehensive assessment: An initial assessment, also called an admission assessment, is performed when the client enters a health care from a health care agency. The purposes are to evaluate the clients health status, to identify functional health patterns that are problematic, and to provide an in-depth, comprehensive database, which is critical for evaluating changes in the clients health status in subsequent assessments. 5
- 6. 2. Problem-Focused assessment: A problem focus assessment collects data about a problem that has already been identified. This type of assessment has a narrower scope and a shorter time frame than the initial assessment. In focus assessments, nurse determine whether the problems still exists and whether the status of the problem has changed (i.e. improved, worsened, or resolved). 6
- 7. 3. Emergency assessment: Emergency assessment takes place in life-threatening situations in which the preservation of life is the top priority. Time is of the essence rapid identification of and intervention for the clients health problems. Often the clients difficulties involve airway, breathing and circulatory problems (the ABCs). Emergency assessment focuses on few essential health patterns and is not comprehensive. 7
- 8. 4. Time-lapsed reassessment: Time lapsed reassessment, another type of assessment, takes place after the initial assessment to evaluate any changes in the clients functional health. Nurses perform time-lapsed reassessment when substantial periods of time have elapsed between assessments 8
- 9. Purposes of Assessment To establish baseline information on the client To determine the clients risk for dysfunction or to identify the life-threatening problem To determine the clients strength To provide data for diagnosis To identify the patients problems To compare the clients current status to baseline data previously obtained. 9
- 10. Methods of Assessment Interview (History taking) Physical examination Review of clinical records Consultation 10
- 11. Assessment consists of 4 separate activities Data collection Data organization Data validation Documenting data 11
- 12. a. Data Collection Data collection is the process of gathering information about a clients health status. It must be both systematic and continuous to prevent the omission of significant data and reflect a clients changing health status. A database is all the information about a client; it includes the nursing health history, physical assessment, and primary care providers history, results of laboratory and diagnostic tests and material contributed by other health personnel. 12
- 13. Types of data The information that is collected during assessment is called data. There are two types of data. Subjective data Objective data 13
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- 15. 1. Subjective data: Subjective data, also referred to as symptoms or covert data It consists of information given by the patient or his relatives to the nurse as in history taking It is given from the patients or relatives own point of view It is also gathered during daily contacts with the persons The symptoms that the patients complains are the examples of the subjective data. For e.g. I have a fever, I could not sleep at night, My legs are swollen, feeling of sadness, blurring vision, pain etc. 15
- 16. Contd 2. Objective data: Objective data, also referred to as signs or overt data The information about the person obtained by the nurses through observation or physical examination or various tests They can be seen, heard, felt, or smelled. For example, a discoloration of the skin or a blood pressure reading are objective data. These data are considered objective because the data are found to be the same by any observer The signs which the examiner finds in the patient are the objective data, e.g. temperature 39 勇C, bluish discoloration of nail-bed. Etc.. 16
- 17. Sample application: types of data Mrs. Shisu, age 47, has come to the clinic afterpassing out twice in the last 2 days. She tells the nurse that she becomes light headed after almost any type of activity. She has experienced some nausea since yesterday and vomited after eating breakfast this morning. She also tells the nurse that she is very nervous about these occurrences because she remembers her mother having similar symptoms when the mother suffered from a brain disorder. The nurse observes that the clients gait is unsteady and her skin is pale. The client also has large bruises on her right arm and the right side of her face, which she states occurred when she fell. 17
- 18. Types of data Subjective Report of fainting Complaint of dizziness Nausea Verbalization of anxiety Self-reported fall Objectives Vomiting Unsteady gait Pale skin Bruises on right side of face and right arm 18
- 19. Sources of data: Sources of data are primary or secondary. The client is the primary source of data. 1. Primary sources- The information collected from the client is considered to be the most reliable, unless the patient is semi conscious, has physical and mental problems. 2. Secondary sources- Family members or other support persons, other health professionals, record and reports, laboratory and diagnostic analysis, and relevant literature are secondary or indirect sources. Infact, all sources other than the client are considered secondary sources. 19
- 20. Characteristics of data Complete Factual Accurate relevant 20
- 21. Contd Data collection methods The principle methods used to collect data are: Observing Interviewing Examining Diagnostic and laboratory test 21
- 22. Contd. 1. Observing: To observe is to gather data by using the senses. Observation is a conscious, deliberate skill that is developed through effort and with an organized approach. Although nurses observe mainly through sight, most of the senses are engaged during careful observations. By carefully watching the client, the nurse can detect nonverbal cues that indicate a variety of feelings, including presence of pain, anxiety, and anger. Observational skills are essential in detecting the early warning signs of physical changes (e.g., pallor and sweating). 22
- 23. Observation has two aspects: a) noticing the data and b) selecting, organizing, and interpreting the data. A nurse who observes that a clients face is flushed must relate that observation to findings such as body temperature, activity, environmental temperature, and blood pressure. 23
- 24. Contd.. 2. Interviewing: An interview is a planned communication or a conversation with a purpose. For example, to get or give information, identify problems of mutual concern, evaluate change, teach, provide support, or provide counseling or therapy. One example of the interview is the nursing health history, which is a part of the nursing admission history. 24
- 25. An interview is a therapeutic interaction that has a specific purpose. The purpose of the assessment interview is to collect information about the clients health history and current status in order to make determinations about the clients health needs. Effective interviewing depends on the nurses knowledge and ability to skillfully elicit information from the client using appropriate techniques of communication. Observation of nonverbal behavior during the interview is also essential to effective data collection. 25
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- 27. Contd 3. Examining: Physical examination or physical assessment is a systematic data collection method that uses observation. To conduct the examination the nurse uses technique of inspection, palpation, percussion and auscultation. 27
- 28. 4. diagnostic and laboratory test Results of laboratory and diagnostic tests can be useful objective data as these values often serve as defining characteristics for various altered health states; these can also be helpful in ruling out certain suspected problems. For example, diabetic clients who are poorly controlled on diet and/or medication will usually have an elevated blood glucose level. The pattern of these types of variations is useful in determining a plan of care. In addition, the effectiveness of nursing and medical interventions and progress toward health restoration are often monitored through laboratory and diagnostic test data. 28
- 29. Analysis of Data Identify abnormal findings Cluster findings into logical groups Localize findings anatomically Localize findings into probable process: Pathological such as inflammatory, metabolic, degenerative Pathophysiological mal functioning, such as congestive heart failure 29
- 30. Analysis cont Psychopathological behavioral, mood disorder, thought process disturbance Construct a working hypothesis from the central findings Match the findings with all causative conditions you know could as associated Eliminate hypothesis that fail to explain the findings Weight the probabilities & select the most likely diagnosis Consider life-threatening & treatable situations Test the hypothesis or obtain further studies Establish a working definition of the problem 30
- 31. Documentation of Data Permanent medico legal record of the patients health status & treatment Record pertinent/relevant positive findings abnormal findings Record pertinent negative findings normal findings, or absence of abnormal findings 31
- 32. b. Organizing Data: The nurse uses a written format that organizes the assessment data systematically. The nurse organizes, or clusters, the information together in order to identify areas of strengths and weaknesses. This process is known as data clustering. The format may be modified according to the clients physical status such as one focused on musculoskeletal data for orthopedic clients. 32
- 33. c. Validating Data: Data verification is the process through which data are validated as being complete and accurate. Once the nurse completes the initial data collection, the data are reviewed for inconsistencies or omissions. The information gathered during the assessment phase must be complete, factual and accurate because the nursing diagnosis and interventions are based on this information. 33
- 34. Contd Validating data helps the nurse complete these tasks: ensure that assessment information is complete, ensure that objective and related subjective data agree, obtain additional information that may have been overlooked and Differentiate between cues and inferences (cues are subjective and objective date that can be directly observed by the nurse; that is, what client says and what the nurse can see, hear, smell or measure. Inferences are the nurses interpretation or conclusions made based on cues). 34
- 35. For example, if a client is confused or unable to communicate, or if two sources provide conflicting data, it is necessary for the nurse to seek further information or clarification. Data verification is done by examining the congruence between subjective and objective data. For example, a client might exhibit nonverbal expressions of pain (e.g., guarding a part of the body, facial grimacing) but verbally deny feeling pain. 35
- 36. d. Documenting data: Assessed data should be recorded and some should be reported immediatey. Accurate documentation is essential and should include all data collected about the client health status. Data are recorded in a factual manner and not interpreted by the nurse. Documentation of data is essential to communicate the information of the patient to the other related health care team members and ensures for the delivery of continuous quality of care. 36
- 37. Copyright 2008 by Pearson Education, Inc. The Nursing Process 37