- Assessment is the systematic and continuous collection organization validation and documentation of data.
- The nurse gathers information to identify the health status of the patient.
- Assessments are made initially and continuously throughout patient care.
- The remaining phases of the nursing process depend on the validity and completeness of the initial data collection.
Review of clinical record
- Client records contain information collected by many members of the healthcare team, such as demographics, past medical history, diagnostic test results and consultations
- Reviewing the client’s record before beginning an assessment prevents the nurse from repeating questions that the client has already been asked and identifies information that needs clarification.
- The purpose of an interview is to gather and provide information, identify problems of concerns, and provide teaching and support.
- The goals of an interview are to develop a rapport with the client and to collect data
- An interview has 3 major stages:
- Opening: purpose is to establish rapport by creating goodwill and trust; this is often achieved through a self – introduction, nonverbal gestures (a handshake), and small talk about the weather, local sports team, or recent current event; the purpose of the interview is also explained to the client at this time.
- Body: during this phase, the client responds to open and closed-ended questions asked by the nurse.
- Closing: either the client or the nurse may terminate the interview, it is important fro the nurse to try to maintain the rapport and trust that was developed thus far during the interview process.
- Types of questions
- Closed questions used in directive interview
- Re____ short factual answers; e.g. “Do you have pain?”
- Answers usually reveal limited amounts of information
- Useful with clients who are highly stressed and/or have difficulty communicating
- Open-ended questions used in nondirective interview
- Encourage clients to express and clarify their thoughts and feelings; e.g. “How have you been sleeping lately?’
- Specify the broad area to be discussed and invite longer answers
- Useful at the start of an interview or to change the subject
- Leading questions
- Direct the client’s answer; e.g. “You don’t have any questions about your medications, do you?”
- Suggests what answer is expected
- Can result in client giving inaccurate data to please the nurse
- Can limit client choice of topic for discussion
- Closed questions used in directive interview
- Collection of information about the effect of the client’s illness on daily functioning and ability to cope with the stressor (the human response)
- Subjective data
- May be called “covert data”
- Not measurable or observable
- Obtained from client (primary source), significant others, or health professionals (secondary sources).
- For example, the client states, “I have a headache”
- Objective data
- May be called “overt data”
- Can be detected by someone other than the client
- Includes measurable and observable client behavior
- For example, a blood pressure reading of 190/110 mmHg.
- Systematic collection of information about the body systems through the use of observation, inspection, auscultation, palpation and percussion
- A body system format for physical assessment is found below:
- General assessement
- Integumentary system
- Head, ears, eyes, nose, throat
- Breast and axillae
- Thorax and lungs
- Cardiovascular system
- Nervous system
- Abdomen and gastrointestinal system
- Anus and rectum
- Genitourinary system
- Reproductive system
- Musculoskeletal system
- Helpful framework for organizing data
- A suggested format for psychosocial assessment is found below:
- Home and Family
- Social, leisure, spiritual and cultural
- Activities of daily living
- Health Habits
- The developmental of Erickson, Freud, Havighurst, Kohlberg and Piaget may also be helpful for guiding data collection
Purposes of assessment
- To establish Database: all the information about a client: it includes:
- The nursing health history
- Physical examination
- The physician’s history
- Results of laboratory and diagnostic tests
- Assessment is part of each activity the nurse does for and with the patient. The purposes is
- To validate a diagnosis
- To provide basis for effective nursing care.
- It helps in effective decision making
- Basis for accurate diagnosis
- It promote holistic nursing care
- To provide effective and innovative nursing care (1. To collecting data for nursing research 2. To evaluation of nursing care)
- The nurse collects data from multiple sources: primary (client) and secondary (family members, support persons, healthcare professionals and records)
- Consultation with individuals who can contribute to the client’s database is helpful in achieving the most complete and accurate information about a client
- Supplemental information from secondary sources (any source other then the client) can help verify information, provide information for a client who cannot do so, and convey information about the client’s status prior to admission
Review of literature
- A professional nurse engages in continued education to maintain knowledge of current information related to health care
- Reviewing professional journals and textbooks can help provide additional data to support or help analyze the client database