In nursing assessment 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. Assessment is part of each activity the nurse does for and with the patient.
Purposes of Nursing Assessment
1 - To establish Database regarding all the information about a client which includes:
a) The nursing health history
b) Physical examination
c) The physician's history
d) Psycho-social health
e) Emotional health
f) Behavioral health
g) Results of laboratory and diagnostic tests
2 - To validate a diagnosis
3 - To provide basis for effective nursing care.
4 - It helps in effective decision making
5 - Basis for accurate diagnosis
6 - It promote holistic nursing care
7 - To provide effective and innovative nursing care
8 - To collecting data for nursing research
9 - To evaluation of nursing care
Types of Nursing Assessment
Assessment types generally depends on the time or situation in which assessment may acquire or the information needed for assessment is usually determined by the health care setting and needs of the client. Usually assessment includes four types;
I. Initial Nursing Assessment or Comprehensive Nursing Assessment
II. Problem Focused Nursing Assessment
III. Time-lapsed Nursing Assessment or ongoing Nursing Assessment
IV. Emergency Nursing Assessment
I - Initial Nursing Assessment or Comprehensive Nursing 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 client’s health status, to identify functional health patterns that are problematic, and to provide in-depth, comprehensive database, which is critical for evaluating changes in the client’s health status in subsequent assessments. It is also called baseline client data including a complete health history and current needs assessment.
II - Problem Focused Nursing Assessment
In this type a problem focus assessment collects data about a problem that has already been identified or reported by a patient. 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). This assessment also includes the appraisal of any new, overlooked, or misdiagnosed problems. In intensive care units, may perform focus assessment every few minute. It is a limited to potential health care risks, a particular need, or health care concern. Also used when short stays are anticipated such as outpatient surgery centers and emergency departments.
III - Time-lapsed Nursing Assessment or ongoing Nursing Assessment
Time lapsed reassessment, is another type of assessment, take place after the initial assessment to evaluate any changes in the client’s functional health. Nurses perform time-lapsed reassessment when substantial periods of time have elapsed between assessments (e.g., periodic output patient clinic visits, home health visits, and health and development screenings). However, when problems are identified during a comprehensive or focused assessment, follow-up is required. An ongoing assessment includes systematic monitoring of specific problems.
IV - Emergency Nursing Assessment
Emergency assessment takes place in life-threatening situations in which the preservation of life is on the top priority. Time is the essence, rapid identification and intervention for the client’s health problems is the goal. Often the client’s difficulties involve airway, breathing and circulatory problems (the ABCs). Abrupt changes in self-concept (suicidal thoughts) or roles or relationships (social conflict leading to violent acts) can also initiate an emergency. Emergency assessment focuses on few essential health patterns and is not comprehensive.
Steps of Nursing Assessment
The first component of the nursing process includes systematic collection, verification, organization, interpretation, and documentation of data. The completeness and correctness of this data relate directly to the accuracy of this component that follow the systematic and continuous process mentioned as:
1 - Collection of Data
2 - Organization of Data
3 - Validation of Data
4 - Data interpretation
5 - Documentation of data.
1 - Collection of data
Data collection is the process of gathering information about a client's health status, includes physical, psychological, emotion, socio-cultural, spiritual factors that may affect client’s health status. Past health history of client (allergies, past surgeries, chronic diseases, use of folk healing methods). It must be both systematic and continuous to prevent the oversight of significant data and reflect a client's changing health status. It is a database having all the information about a client includes the nursing health history, physical assessment, primary care provider's history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. To collect data accurately, both the client and nurse must actively participate. Data can be of subjective or objective and constant or variable types, and from a primary or secondary source.
Types of data (For nursing assessment):
When performing an nursing assessment the nurse gathers subjective and objective data.
A) Subjective data (symptoms or covert data):
The verbal statements provided by the Patient based on patient’s own point of view and include perceptions, feelings, and concerns. The primary method of collecting subjective data is the interview. The health history, a review of the client’s functional health patterns. Statements about nausea and descriptions of pain and fatigue are examples of subjective data.
B) Objective data (signs or overt data):
The detectable by an observer or can be measured or tested against an accepted standard. It is the observable and measurable data that are obtained through both standard assessment techniques performed during the physical examination and the results of laboratory and diagnostic testing. They can be seen, heard, felt, or smelt, and they are obtained by observation or physical examination. For example: discoloration of the skin
Data collection methods:
a. Observing: To observe is to gather data by using the senses.
b. Interviewing: An interview is a planned communication or conversation with a purpose. (Nursing Assessment History Taking)
c. Examining: Performance of a Physical Examination. The physical examination is often guided by data provided by the patient. A head-to-toe approach is frequently used to provide systematic approach that helps to avoid omitting important data
Sources of data:
Data can be obtained from primary or secondary sources.
i- The primary source of data is the patient. In most instances the patient is considered to be the most accurate reporter. The alert and oriented patient can provide information about past illness and surgeries and present signs, symptoms, and lifestyle. When the patient is unable to supply information because of deterioration of mental status, age, or seriousness of illness, secondary sources are used.
ii- The Secondary sources of data include family members, significant others, medical records, diagnostic procedures. Members of the patient's support system may be able to furnish information about the patient's past health status, current illness, allergies, and current medications. Other health team professionals are also helpful secondary sources (Physicians, other nurses.)
2 – Organizing data
Collected data must be organized so as to be useful to the health care professional collecting the data and to others involved in the client’s care. After being organized into categories, the data are clustered into groups of related pieces. Data clustering is the process of putting data together in order to identify areas of the client’s problems and strengths. The nurse uses a written or computerized format that organizes the assessment data systematically. The format may be modified according to the client's physical status.
A – Body System Model
The Body systems model (also called the medical model or review of systems) focuses on the client’s major anatomic systems. The framework allows nurses to collect data about past and present condition of each organ or body system and to examine thoroughly all body systems for actual and potential problems.
B – Gordon’s Functional Health Patterns:
The client’s strengths, talents and functional health patterns are an integral part of the assessment data. An assessment of functional health focuses on client’s normal function and his or her altered function or risk for altered function.
1) Health perception-health management pattern.
2) Nutritional-metabolic pattern
3) Elimination pattern
4) Activity-exercise pattern
5) Sleep-rest pattern
6) Cognitive-perceptual pattern
7) Self-perception-concept pattern
8) Role-relationship pattern
9) Sexuality-reproductive pattern
10) Coping-stress tolerance pattern
11) Value-belief pattern
3 – Validating of data
The information gathered during the assessment phase must be complete, factual, and accurate because the nursing diagnosis and interventions are based on this information. Validation is the act of "double-checking" or verifying data to confirm that it is accurate and factual.
A – Purposes of data validation:
a) Ensure that data collection is complete
b) Ensure that objective and subjective data agree
c) Obtain additional data that may have been overlooked
d) Avoid jumping to conclusion
e) Differentiate cues and inferences
B – Data Requiring Validation
Not every piece of data you collect must be verified. For example: you would not need to verify or repeat the client’s pulse, temperature, or blood pressure unless certain conditions exist. Conditions that require data to be rechecked and validated include:
a) Discrepancies or gaps between the subjective and objective data. For example, a male client tells you that he is very happy despite learning that he has terminal cancer.
b) Discrepancies or gaps between what the client says at one time and then another time. For example, your female patient says she has never had surgery, but later in the interview she mentions that her appendix was removed at a military hospital when she was in the navy
c) Findings those are very abnormal and inconsistent with other findings. For example, the client has a temperature of 104oF degree. The client is resting comfortably. The client’s skin is warm to touch and not flushed.
C – Methods of validation
a) Recheck your own data through a repeat assessment. For example, take the client’s temperature again with a different thermometer.
b) Clarify data with the client by asking additional questions. For example: if a client is holding his abdomen the nurse may assume he is having abdominal pain, when actually the client is very upset about his diagnosis and is feeling.
c) Verify the data with another health care professional. For example, ask a more experienced nurse to listen to the abnormal heart sounds you think you have just heard.
d) Compare you objective findings with your subjective findings to uncover discrepancies. For example, if the client state that she “never gets any time in the sun” yet has dark, wrinkled, suntanned skin, you need to validate the client’s perception of never getting any time in the sun
4 – Interpreting the Data
After data is collected, the nurse can begin developing impressions or inferences about the meaning of the data. Organizing data in clusters helps the nurse recognize patterns of response or behavior. When data are placed in clusters, the nurse can:
• Distinguish between relevant and irrelevant data.
• Determine whether and where there are gaps in the data.
• Identify patterns of cause and effect.
5 – Documenting data:
To complete the assessment phase, the Assessment data must be recorded and reported. The nurse must decide which data should be immediately reported to the head nurse and/or physician and which data can just be recorded. Accurate documentation is essential and should include all data collected about the client's health status. Data are recorded in a factual manner and not interpreted by the nurse.
A – Purposes of documentation
a) Provides a chronological source of client assessment data and a progressive record of assessment findings that outline the client’s course of care.
b) Ensures that information about the client and family is easily accessible to members of the health care team; provides a vehicle for communication; and prevents fragmentation, repetition, and delays in carrying out the plan of care.
c) Establishes a basis for screening or validation proposed diagnoses.
d) Acts as a source of information to help diagnose new problems.
e) Offers a basis for determining the educational needs of the client, family, and significant others.
f) Provides a basis for determining eligibility for care and reimbursement. Careful recording of data can support financial reimbursement or gain additional reimbursement for transitional or skilled care needed by the client.
g) Constitutes a permanent legal record of the care that was or was not given to the client.
h) Provides access to significant epidemiological data for future investigations and research and educational endeavors.
B – Guidelines for documentation
a) Document legibly or print neatly in erasable ink.
b) Use correct grammar and spellings.
c) Avoid wordiness that creates redundancy
d) Use phrases instead of sentences to record data
e) Record data findings, not how they were obtained
f) Write entries objectively without making premature judgments or diagnosis
g) Record the client’s understanding and perception of problems
h) Avoid recording the word “normal” for normal findings
i) Record complete information and details for all client symptoms or experiences
j) Include additional assessment content when applicable
Support objective data with specific observations obtained during the physical examination
"The Nursing Assessment" - First Component of Nursing Process | POST RN BSN Nursing Resources
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