Nursing Assessment: Terry White, MBA, BSN
Nursing Assessment: Terry White, MBA, BSN
Nursing Assessment: Terry White, MBA, BSN
1. assessment
2. diagnosis
3. planning
4. implementation
5. evaluation.
Evaluation Assessment
Implementation Diagnosis
Planning
The Assessment
Assessment
Assessment
Is the systematic and continuous:
collection
organization
validation
documentation of data.
The Process
Assessment
Documenting
Collect data Organize data Validate data
data
The Process
Assessment is part of each activity the nurse does for and with
the patient.
The purposes is
1.To validate a diagnosis
2.To provide basis for effective nursing care.
3.It helps in effective decision making
4.Basis for accurate diagnosis
5.It promote holistic nursing care
6.To provide effective and innovative nursing care
7.To collecting data for nursing research
8.To evaluation of nursing care
Types of Assessment
Assessment
A. Collection of data
a) Subjective data collection
b) Objective data collection
B. Validation of data
C. Organization of data
D. Recording/documentation of data
Collection of Data
Inspection
Palpation
Percussion
Auscultation
The innovative Telemetry Monitoring
System
Assessment techniques - Inspection
Presence of lumps or
masses
Tenderness, or pain
Assessment techniques Percussion
Direct
Indirect
Blunt percussion
Percussion Sounds
Listening to sounds
produced by the body
Environment &
Technique
Equipment
General survey
Head to toe or systems
approach
Minimize exposure
Areas to assess first
unaffected areas, external
before internal parts
Physical Health Exam-General Survey
Appearance
Age, skin color, facial features
Behavior
Facial expression, mood/affect, speech, dress, hygiene
Cognition
Level of Consciousness and Orientation (x4)
Biographical data
Reason for Seeking Care
History of Present Illness
Past Health
Accidents and Injuries
Hospitalizations and Operations
Family History
Review of Systems
Functional Assessment ( Activities of Daily
Living)
Perception of Health
Sources of Data
Data can be obtained from primary or secondary sources.
Not every piece of data you collect must be verified. For example:
you would not need to verify or repeat the clients pulse,
temperature, or blood pressure unless certain conditions exist.
Conditions that require data to be rechecked and validated include:
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.
Data Requiring Validation
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
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
clients skin is warm to touch and not flushed.
Methods of validation
Recheck your own data through a repeat assessment. For example, take the
clients temperature again with a different thermometer.
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
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.
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 clients
perception of never getting any time in the sun
Organizing data
The clients strengths, talents and functional health patterns are an integral
part of the assessment data. An assessment of functional health focuses on
clients normal function and his or her altered function or risk for altered
function.
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
Documenting Data:
Feeding
0 = unable
0 5 10
5 = needs help cutting, spreading butter, etc., or requires modified diet
10 = independent
Bathing
0 = dependent 0 5
5 = independent (or in shower)
Grooming
0 = needs to help with personal care 0 5
5 = independent face/hair/teeth/shaving (implements provided)
Dressing
0 = dependent
0 5 10
5 = needs help but can do about half unaided
10 = independent (including buttons, zips, laces, etc.)
Bowels
0 = incontinent (or needs to be given enemas)
0 5 10
5 = occasional accident
10 = continent
Bladder
0 = incontinent, or catheterized and unable to manage alone
0 5 10
5 = occasional accident
10 = continent
Toilet Use
0 = dependent
0 5 10
5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping)
Transfers (bed to chair and back)
0 = unable, no sitting balance
5 = major help (one or two people, physical), can sit 0 5 10 15
10 = minor help (verbal or physical)
15 = independent
Mobility (on level surfaces)
0 = immobile or < 50 yards
5 = wheelchair independent, including corners, > 50 yards 0 5 10 15
10 = walks with help of one person (verbal or physical) > 50 yards
15 = independent (but may use any aid; for example, stick) > 50 yards
Stairs
0 = unable
0 5 10
5 = needs help (verbal, physical, carrying aid)
10 = independent