NURSING PROCESS - ASSESSMENT

• Assessment is the foundation step of nursing process.
• It consists of systematic and orderly collection of information pertaining to and about the health status of the client.
• It includes the client’s perceived needs, health problems, related experiences, health practices, values and lifestyles.
• The information obtained helps to make nursing diagnoses and to develop a plan of care.

PURPOSE OF ASSESSMENT

• To establish a data base (all the information about the client) such as -
• Nursing health history
• Physical assessment
• The physician’s history & physical examination
• Results of laboratory & diagnostic tests
• Material from other health personnel

TYPES OF ASSESSMENT

1. Initial assessment – Assessment performed within a specified time on admission. To establish a complete database for problem identification, reference and future comparison. Ex: nursing admission assessment
2. Problem-focused assessment – Ongoing process integrated with nursing care, To use to determine status of a specific problem identified in an earlier assessment. Ex: problem on urination-hourly assessment of fluid intake & urine output hourly
3. Emergency assessment – Rapid assessment done during any physiologic/physiologic crisis of the client, to identify life threatening problems. Ex: Rapid assessment of a client’s airway, breathing status & circulation after a cardiac arrest; Assessment for suicidal tendency or potential for the violence.
4. Time-lapsed assessment – reassessment of client’s functional health pattern done several months after initial assessment to compare the client’s current status to baseline data previously obtained. Ex: Follow-up assessment.

COMPONENTS OF ASSESSMENT PHASE

1. Collection of data
2. Organization of data
3. Validation of data
4. Analyzing of data
5. Documentation of data

COLLECTION OF DATA

• Collection of data is the process of gathering of information about the client’s health status.
• It includes accumulation of comprehensive information about the client on initial assessment.
• It must be both systematic and continuous to prevent the omission of significant data and reflect a client’s changing health status.
• Database is the all information about a client; It includes –
• The nursing health history, physical assessment, primary care provider’s history, and physical examination, result of laboratory and diagnostic tests and material contributed by the other health care personnel.
• Current/present problems of client (pain, nausea, sleep pattern, religious practices, meds or treatment the client is taking now)
• Past health history of client (allergies, past surgeries, chronic diseases, use of folk healing methods)
• Physical, psychological, emotion, socio-cultural, spiritual factors that may affect client’s health status
• The gathering of information about the client’s well-being status includes:
• Strengths as well as weaknesses of patient,
• Response of patient to his health concerns,
• Analysis of the circumstances associated with patient’s well-being status,
• Knowledge related to health and well-being,
• Beliefs and values about health,
• Life-style,
• Health-related goals, and
• Support system.

TYPES OF DATA
Subjective data

• Also referred to as Symptom/Covert data
• Information from the client’s point of view or are described by the person experiencing it.
• Information supplied by family members, significant others and other health professionals are considered subjective data.
• 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

SOURCE OF DATA

• Primary source - Data directly gathered from the client using interview and physical examination.
• Secondary source - Data gathered from client’s family members, significant others, client’s medical records/chart, other members of health team, and related care literature/journals.

METHODS OF DATA COLLECTION
a) Interview

• Interview is 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.
• The client interview is conducted to gather specific information about the client.
• The purposes of interview in this phase of assessment are:
• To collect specific information required for diagnosis and planning.
• To establish a trusting nurse-client relationship.
• The allow the client to participate in identification of problems and goal setting.
• The assist nurse to determine areas for specific investigation during the process of assessment.
• To assist nurse to gain insight into client’s ability to function, severity of his illness and his behavior.

b) Observation

• Observation is a method of data collection through the conscious use of 5 senses — sight, smell, hearing and feeling (touch) and instruments.
• Observation is a skill that requires practice.
• Through the use of senses, the nurse collects data about client, his family and his environment.
• Through observation, nurse can also understand the interaction between the client and the environment.
• Each observation finding requires further investigation to confirm the impression.

c) Examination

• Systematic data collection to detect health problems using unit of measurements, physical examination techniques (IPPA), interpretation of laboratory results.
• Substantial data are also obtained by physical examination of the client.
• Nurse uses physical examination with the following purposes:
• To define the client’s response to the disease process.
• To establish baseline data to evaluate the nursing interventions.
• To compare the efficiency of medical and nursing interventions.
• To substantiate subjective data obtained during interview and other nurse-client interaction.
• Physical examination includes various techniques such as inspection, palpitation, percussion, auscultation.
• Physical examination Should be conducted systematically:
• Cephalocaudal approach – head-to-toe assessment
• Body System approach – examine all the body system
• Review of System approach – examine only particular area affected

ORGANIZATION OF DATA

• Data is organize systematically –
• Either in written or computerized format such as Nursing Health History, Nursing Assessment, Or Nursing Data-base Form.
• These all formats are based on the conceptual models. These are Maslow’s basic needs, Body System Model and Gordon’s 11 Functional Health Patterns.

VALIDATION OF DATA

• The information gathered during assessment phase must be complete, factual, and accurate because the nursing diagnoses and interventions are based on this information.
• Validation is the act of “double-checking” or verifying data to confirm that it is accurate and complete.
• Purposes of data validation
• 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.
• For Example:
• A nurse observes the cues that are an incision is red, hot and swollen wound = nurse make inference that the incision is infected.
• A nurse observes the cues that the client’s skin is dry = nurse make inference that the client is dehydrated.

ANALYZE DATA

• Compare data against standard and identify significant cues.
• Standard/norm are generally accepted measurements, model, pattern.
• For Ex:
• Normal vital signs,
• Standard weight and height,
• Normal laboratory/diagnostic values,
• Normal growth and development pattern.

DOCUMENTING DATA

• The documentation is recording of data accumulated during the assessment.
• It is the integral part of all the phases of the nursing process.
• Nurse records all data collected about the client’s health status
• Data are recorded in a factual manner not as interpreted by the nurse
• Record subjective data in client’s word; restating in other words what client says might change its original meaning.

Purposes of Documentation

• To communicate the information to the other members of the health team and thereby prevent repetition of asking same questions by other personnel.
• To facilitate the delivery of quality client care. The information collected allows the nurse to develop preliminary nursing diagnoses, outcomes and nursing interventions, which later on can be updated, clarified to provide quality care.
• To provide a mechanism for the evaluation of individual client care.
• To provide a legal record of the care provided to the client.
• To serve as a source for identification of research topics for nursing practice.

Guidelines for Documentation for a Nurse

1. Make entries very objectively without personal opinion, biases. Use quotation marks to clearly identify the statements. For e.g. client’s description of illness: “I have a lump in the abdomen and have come to get it operated”.
2. Support description or interpretations of objective data by specific observation. For e.g. nurse interprets excessive crying as - Subjective data -moderate hypothermia in a baby; Objective data: Baby looking pale, skin mottled, skin temperature 35º C.
3. Avoid using generalised terms like “good”, “fair”, “normal”. These descriptions do not mean same to everyone. What is “good” for one person may mean “fair” to another. For e.g. instead of writing bowel pattern - normal, record “bowels moved everyday without the use of laxatives.”
4. Avoid using superfluous information. For e.g. “The child had swallowed kerosene, one year back and was taken to nursing home, there the child was kept in ICU and discharged after one week.” This information can be written as “History of kerosene poisoning one year back, treated in private agency and discharged after one week.”
5. Record the findings with description like size and shape. These kinds of descriptions are important to evaluate the effectiveness of nursing intervention at a later date. For e.g. description of wound will include information related to colour, size, location, drainage.
6. Write legibly and correct any errors by drawing a line so that the original entry is also readable e.g. Pain chronic
7. Use correct language and spelling.
8. Use abbreviations approved for use.

BIBLIOGRAPHY

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