Nursing assessment

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Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status.
Contents

1 Stage one of the nursing process 2 Components of a nursing assessment

o o o

2.1 Nursing history 2.2 Psychological and social examination 2.3 Physical examination

3 Documentation of the assessment

3.1 Assessment tools

4 See also 5 References 6 Bibliography

[edit]Stage

one of the nursing process

Assessment is the first stage of the nursing process in which the nurse carries out a complete and holistic nursing assessment of every patient's needs, regardless of the reason for the encounter. Usually, an assessment framework, based on a nursing model is used. The purpose of this stage is to identify the patient's nursing problems. These problems are expressed as either actual or potential. For example, a patient who has been rendered immobile by a road traffic accident may be assessed as having the "potential for impaired skin integrity related to immobility".
[edit]Components

of a nursing assessment
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[edit]Nursing

history

Taking a nursing history prior to the physical examination allows a nurse to establish a rapport with the patient and family. Elements of the history include: the client's overall health status, the course of the present illness including

symptoms, the current management of illness, the client's medical history (including familial medical histroy), social history, how the client perceives his illness, a criminal background check, and any previous 911 calls.
[edit]Psychological
[1]

and social examination

The main areas considered in a psychological examination are intellectual health and emotional health. Assessment of cognitive function, checking for hallucinations and delusions, measuring concentration levels, and inquiring into the client's hobbies and interests constitute an intellectual health assessment. Emotional health is assessed by observing and inquiring about how the client feels and what he does in response to these feelings. The psychological examination may also include the client's perceptions (why they think they are being assessed or have been referred, what they hope to gain from the meeting). Religion and beliefs are also important areas to consider. The need for a physical health assessment is always included in any psychological examination to rule out structural damage or anomalies.
[edit]Physical

examination

A nursing assessment includes a physical examination: the observation or measurement of signs, which can be observed or measured, or symptoms such as nausea or vertigo, which can be felt by the patient.
[2]

The techniques used may include Inspection, Palpation, Auscultation and Percussion in addition to the "vital signs" of temperature, blood pressure, pulse and respiratory rate, and further examination of the body systems such as the cardiovascular or musculoskeletal systems.
[edit]Documentation
[3]

of the assessment

The assessment is documented in the patient's medical or nursing records, which may be on paper or as part of the electronic medical record which can be accessed by all members of the healthcare team.
[edit]Assessment

tools
[4]

A range of instruments has been developed to assist nurses in their assessment role. These include: independence in activities of daily living
[8] [5] [6]

the index of
[7]

, the Barthel index , the Crighton Royal behaviour rating scale , the Clifton
[9]

assessment procedures for the elderly , the general health questionnaire schedule
[10]

,and the geriatric mental health state

Other assessment tools may focus on a specific aspect of the patient's care. For example, the Waterlow score and the Braden scale deals with a patient's risk of developing a Pressure ulcer (decubitus ulcer), the Glasgow Coma Scale measures the conscious state of a person, and various pain scales exist to assess the "fifth vital sign".
[edit]

nursing assessment,
an identification by a nurse of the needs, preferences, and abilities of a patient. Assessment includes an interview with and observation of a patient by the nurse and considers the symptoms and signs of the condition, the patient's verbal and nonverbal communication, the patient's medical and social history, and any other information available. Among the physical aspects assessed are vital signs, skin color and condition, motor and sensory nerve function, nutrition, rest, sleep, activity, elimination, and consciousness. Among the social and emotional

factors included in assessment are religion, occupation, attitude toward hospital and health care, mood, emotional tone, and family ties and responsibilities. Assessment is extremely important because it provides the scientific basis for a complete nursing care plan.

it is systematic and continuous collection, validation and communication of client data as compared to what is standard/norm. it includes the clients 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 physicians 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 clients airway, breathing status & circulation after a cardiac arrest. d. time-lapsed assessment reassessment of clients functional health pattern done several months after initial assessment to compare the clients current status to baseline data previously obtained. Activities:
1. 2. 3. 4. 5. 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

a. gathering of information about the client includes physical, psychological, emotion, socio-cultural, spiritual factors that may affect clients 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 clients 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.

a.

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. Interview 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. Examination systematic data collection to detect health problems using unit of measurements, physical examination techniques (IPPA), interpretation of laboratory results. should be conducted systematically:

a. a.

a. b. c.

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:
a. b. Primary source data directly gathered from the client using interview and physical examination. Secondary source data gathered from clients family members, significant others, clients 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 clients 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:
a. b. c. d. e. 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. - Maslows basic needs - Body System Model - Gordons Functional Health Patterns:
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 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 clients health status data are recorded in a factual manner not as interpreted by the nurse record subjective data in clients word; restating in other words what client says might change its original meaning.