Nursing assessment

Nursing Assessment

1. NURSING
ASSESSMENT
By-
DeveshwarP.D.

2. NURSINGASSESSMENT
Definition:
Assessmentreferstothecollectionand
interpretationofclinicalinformation.It
focusesongatheringthedataaboutaclient's
stateofwellness,functionalability,physical
status,strengthsandresponsestoactualand
potentialhealthproblems.(Gordon,1987;
1994)
Assessment=Observationofthepatient
+Interviewofpatient,family&SO+
examinationofthepatient+Reviewof
medicalrecord.
PURPOSESOFNURSINGASSESSMENT:-
1)Togatherinformationregarding
client'shealth.

3. 2)Todetermineclient'snormalfunction.
3)Toorganizethecollectedinformation.
4)Toconfirmhypothesisgrowingoutof
thenurse'sinterview.
5)Toenhanceinvestigationofnursing
problems.
6)Toframenursingdiagnosis.Itincreases
greatermanagingskillofhandlingpatient's
problem.
7)Toidentifythehealthproblems.To
identifyclient'sstrengths.
8)Toidentifyneedforhealthteaching.
9)Toprovidedataforthediagnosticphase

4. TYPESOFASSESSMENT
1)InitialAssessment:istheassessment
donewithinspecifiedtimeafteradmission
toahealthcareagency.Thisassessmentis
doneassoonasclientcomestoHospital
andisverycomprehensive.Itgathersdata
consideringallaspectsoftheclient'shealth.
2)FocusAssessment:Thisisdaily
assessmentdonebynursingpersonnelof
admittedclient.Itisanongoingprocess
integratedwithnursingcare.Ithelpsin
determiningthestatusofspecificproblem
identifiedininitialassessment.
-Inthisassessment,nursemayidentify
new/overlookedproblemsormisdiagnosed
problem.
-Focusassessmentconcentrateson
collectingdataaboutaproblemalready
identified.
-Nursedailyevaluatesthestatusof

5. identifyingproblemwhetheritisimproved
ordeteriorated.
eg:NurseislookingafteraHeadInjury
Patient.Herfocuswillbeon"GCSScale,
3)EmergencyAssessment:Emergency
assessmentisdone,ifclientassueny
physiologicorpsychologiccrisis.Ithelpsto
identifylifethreateningproblems.Thefocus
isonpreservingthelife.
e.g.:SuddenBPfall,patienthavesuicidal
thoughts,Airwayobstructionunconscious.
4)TimeLapsedAssessment:This
assessmentisdoneseveralmonths/weeks
afterinitialassessment.Ithelpsin
comparingtheclient'scurrenthealthstatus
fromthebaselinedatasimilartofocus
assessment;italsoevaluatesthestatusof
problemalreadyidentified.
e.g.:Assessmentisdoneaspatientcomes

6. forfollowup.Thistypeofassessmentis
lesscomprehensive.
COMPONENTSOFASSESSMENT
l.COLLECTINGDATA
Datacollectionistheprocessofgathering
informationaboutclient'shealthstatus.It
includesthenursinghealthhistory,physical
assessment,physician'shistory,physical
examination,laboratoryresults,diagnostic
tests.Datashouldincludepasthistoryaswell
aspresentcomplaints.
Whilecollectingdata,nurseshouldkeepin
mindfollowingpoints:
-Datacollectionmustbesystematic&
continuoustopreventtheomissionof
significant
Datacollectedshouldberelevanttoactual
orpotentialhealthproblems.

7. Datacollectedshouldbedescriptive,
conciseandcompleteandaccurate.
A.-TYPESOFDATA

8. B.SOURCESOFDATA
B.1.-PrimarySources:
Client:Clientisthebestsourceof
informationunlessheistooill,confused,he
providessubjectivedata.Heprovidesmost
accurateinformationabouthealthcareneeds,
lifestylepatterns,presentpastillness,
perceptionofsymptoms.
B.2.-SecondarySources:
(i)FamilyandSignificantothers:Whoknows
theclientwellcansupplementinformation
providedbyclient.
(ii)HealthCareteam:Everymemberofhealth
careteamisapotentialsourceof
information.Theycanidentifyand
communicatedataaswellasverify
informationfromothersources.
(iii)Records:Medicalrecords(pasthealth
pattern,immunization),Recordsof

9. therapiesbyotherhealthprofessionals,
Laboratoryrecordsetc.providesaswellas
canverifytheinformation.
(iv)Reviewofbooksandkeepinguptodata
knowledgeisveryimportantfornurseasit
providesadditionalinformation.
METHODSOFDATACOLLECTION
1.Observation:Usetogatherdatabyusing
the5sensesandinstruments.
2.Interview:Aplanned,purposeful
communicationwiththeclienttoget
information,identifyproblems,evaluate
change,toteachortoprovidesupportor
counseling.
3.Examination:Systematicdatacollectionto
detecthealthproblemsusingunitof
measurements,physicalexamination
techniques,interpretationoflaboratory
results.

10. Physicalexaminationshouldbeconducted
systematically:
Cephalocaudalapproach—head-to-toe
assessment
BodySystemapproach—examineallthe
bodysystem
ReviewofSystemapproach—examine
onlyparticularareaaffected
ll.ORGANISINGDATA
Inordertoobtaindatasystematically,a
professionalnurseusesanorganized
assessmentframework.
Gordon'stypologyof11(eleven)nursing
functionalhealthpattern.
Theclient'sstrengths,talentsandfunctional
healthpatternsareanintegralpartofthe
assessmentdata.Anassessmentof
functionalhealthfocusesonclient'snormal
functionandhisorheralteredfunctionorrisk
foralteredfunction

11. 1.Healthperception-healthmanagement
pattern.
2.Nutritional-metabolicpattern
3.Eliminationpattern
4.Activity-exercisepattern
5.Sleep-restpattern
6.Cognitive-perceptualpattern
7.Self-perception-conceptpattern
8.Role-relationshippattern
9.Sexuality-reproductivepattern
10.Coping-stresstolerancepattern
11.Value-beliefpattern
Ill.VALIDATINGDATA
Insimplewords,validationmeanscross
checkingthecollectedinformation.Making
surethatthecollectedinformationisfactual
ortrue.

12. Validationofcollecteddatacanbedoneby
following.
Recheckthecollecteddatae.gchecking
pulsefromallpulsesmeasuringBPfrom
otherside.
Confirmthesubjectivethroughobjective
data.
Asksomeotherexpert,professionalto
collectthesamedata.
e.g.:Whilegradingthepressureulcer,you
mayconsultphysicianorotherexperienced
nurse.
Recheckdatawhichisextremely
abnormale.g.measurethebodyweightof
obeseinfantusingtwodifferentscales.
Clarifyclient'sstatementsbysharing
observationswithclient,familymembers.
Clarifyanyambiguousorvague
statements.
Usereferencessuchastextbooks,
journals,researchstudiestoenhanceknow
-ledgeandskill.

13. IV.RECORDINGDATA
Tocompletetheassessmentphaseof
nursingprocess,recording/documentationis
veryimportant.Recordingofthecollected
datashouldbedonesystematically.Itcanbe
doneeitherontheassessmentrecordor
computerizedassessmentrecorddepending
uponhospitalpolicies.
Purposesofdocumentation
Therearefollowingpurposesof
documentation:-
1.Providesachronologicalsourceofclient
assessmentdataandaprogressiverecord
ofassessmentfindingsthatoutlinethe
client'scourseofcare.
2.Ensuresthatinformationaboutthe
clientandfamilyiseasilyaccessibleto

14. membersofthehealthcareteam;provides
avehicleforcommunication;andprevents
fragmentation,repetition,anddelaysin
carryingouttheplanofcare.
3.Establishesabasisforscreeningor
validationproposeddiagnoses.
4.Actsasasourceofinformationtohelp
diagnosenewproblems.
5.Offersabasisfordeterminingthe
educationalneedsoftheclient,family,and
significantothers.
6.Providesabasisfordetermining
eligibilityforcareandreimbursement.
Carefulrecordingofdatacansupport
financialreimbursementorgainadditional
reimbursementfortransitionalorskilled
careneededbytheclient.
7.Constitutesapermanentlegalrecordof
thecarethatwasorwasnotgiventotheclient.
8.Providesaccesstosignificant
epidemiologicdataforfutureinvestigations
andresearchandeducationalendeavors.