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By: Ms. Shanta Peter

NURSING HEALTH

ASSESSMENT

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ASSESSMENT

Act of Evaluation

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OBJECIVES :

• Discuss the role of Nurses in Health Assessment Process

• List and explain the types, methods techniques, components of Assessment

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• Health assessment is an essential nursing function which provides foundation for quality nursing care and intervention

• It helps to identify the strengths of the clients in promoting health

• Health assessment helps to identify client’s needs, clinical problems

• To Evaluate responses of the person to health problems and intervention

Health Assessment

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NURSE &

Health Assessment

An accurate and thorough Health Assessment Reflects the KNOWLEDGE & SKILLS of a PROFESSIONAL NURSE

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ASSESSMENT Is the first step to determine heath status. It is gathering of information to have all the “necessary puzzle pieces” to make a clear picture of the person’s health statusDefinition : Assessment is the deliberate and systematic

collection of data to determine clients current and past

health status, functional status and to determine client’s

present and coping pattern

( Carpenito)

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• Assessment is a part of each activity the nurse does for and

with the patient (Atkinson & Muray – 1991

Nursing assessment focus upon the client’s response to a health problem

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“ Nursing assessment should include client’s

perceived needs, health problems related

experience, health practices values and life styles”

( Bandman and Bandman (1995)

• To be most useful- the data collected should be relevant to a particular health problem

• Therefore – nurses should think critically about what to assess

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Assessment identifies the pt’s strengths and limitations • It is a done continuously

through out the nursing Process

• Initial assessment baseline data identify nsg diagnoses develop plan

Implement plan assess pt response

Finally you assess the effectiveness of your plan for the care of your pt

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• What you do?

• Where do you begin ?

You begin with Assessment

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Types of patients & Assessment

• Pediatric – neonate ,infant, children of all categories)• Adolescent • Young adults & adults• Geriatric/elderly

ConsciousUnconscious Delirious

• Psychiatric – Different categories • Hysteric

ACUTE --- CHRONIC patients

Purposes of Assessment

1. To collect data pertinent to the patient’s health status – subjective /objective

2. To identify deviations from normal 3. To discover the patients

strengths,limitations and coping resources 4. To pinpoint actual problems 5. To spot factors that place the pt at risk of health problems 6. To build rapport with patient and family 15

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TYPES OF ASSESSMENT

INITIAL Assessment

FOCUS Assessment

EMERGENCY Assessment

TIME LAPSED

Assessment

ASSESSMENT

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Initial Assessment It is done within specified time after admission to Hospital Purpose: To establish a complete data base for problem identification, reference and future comparison Eg: Admission assessment

Focus or Ongoing Assessment Purpose: To determine the status of a specific problem identified in the earlier assessment & to identify new or overlooked problem

Eg: Hrly fluid intake output assessment

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Emergency AssessmentDuring any physiologic and psychologic crisis of the patient

Purpose: To identify life threatening problems eg. ●ABC assessment in Cardiac arrest ●Assessment of suicidal attempt on violence

Time lapsed Assessment Several months after the initial assessment Purpose: To compare current status to baseline data previously obtained Eg Reassessment of clients functional health patterns in home care

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On-Going Assessment

• Ongoing – Systematic monitoring of specific problems

Eg. Pain Assessment -( Pain score )

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Methods of Assessment

The primary methods are –

●Observing ●Interviewing ●Examining

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“The most practical lesson that can be given to a nurse to teach them what to observe “ Florence Nightingale ( 1859)

“For it may be said, not that the habit of ready and correct observation will by itself make us useful nurses. But that without it we shall be useless with all our devotion “

(Nursing- what it is and what it not : F. Nightingale Page 160. (1860)

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Observing Is a conscious deliberate skill developed only through and with an organized approach. Eg. Data observed with 4 senses – vision, hearing, smell and touch

Interviewing Is a planned communication or a conversation with a purpose Eg. History taking 2 approaches : Directive , non directive

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EXAMINING Physical Examination• Systematic data collection method –

Observational skills to detect health problems Assessment sequencing• Head – to- Toe assessment • Body system assessment (Signs and symptoms

– complaints – lead to clues )

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The Art of Physical Examination …

Using Techniques of –• Inspection• Palpation• Percussion • Auscultation

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INSPECTION : close and careful visualization of the person and of each body system Eg Rashes…. Color changes … edema

PALPATION • Temp •Texture • Moisture •organ size & location • Rigidity & spasticity •Crepitation /vibration • Position& size •Tenderness/pain •Presence of lumps & masses

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PERCUSSION : Assess underlying structures oflocation, size, density of underlying tissues

AUSCULTATION :Listening to sounds produced by the body • Stethoscope -- • Doppler• Feto- scope

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4 Closely Related Activities

ASSESSMENT

Process

Collecting Data

Validating Data

Documenting Data

Organizing Data

REPORT DATA

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1. Collecting Data : Gathering Information

Sources of data Primary or Secondary PRIMARY SOURCE ----- patient – Alert, oriented patient is most reliable source Aged, mentally deterioration seriously ill ???SECONDARY SOURCE – Family members , significant others, medical records, diagnostic procedures

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1. COLLECTING DATA Process of gathering information Nurse collects …..A. Subjective –(Symptom) Verbal statement by the patient Eg… Nausea , pain , fatigue ,itching

B. Objective--- (Signs) (overt ) data -Detected by an observer - can be measured over an accepted standard Can be seen, felt, heard, smelt – information by observation or examination Eg. Discoloration of the skin

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PQRST Method for PAIN Assessment

• O = Onset What you were doing when the pain started ?

Was the onset sudden or gradual ?• P = Provokes - What causes pain? What makes it better? What makes it Worse?• Q = Quality What does it feel like? Is it sharp? Dull?

Stabbing? Burning? Crushing? ( Try to let patient describe the pain)

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• R = Radiates Where does the pain radiate?– Is it in one place?–Does it go anywhere else?

• Did it start elsewhere and now localized to one spot?

• S = SeverityHow severe is the pain on a scale of 1 - 10

(This is a difficult one as the rating will differ from patient to patient )• T = Time–Time pain started?–How long did it last?

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While Collecting data …..

When you communicate to collect data Aware of verbal /nonverbal messages to patient • Genuineness : be open ,honest and sincere

with patient • Respect : be Non judgemental, let him feel

accepted as a unique individual• Empathy: Is knowing what patient means and

acknowledge and understanding how he /she feels

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ORGANIZING DATA

• Cluster the data into groups of information ( identify the pattern of illness) (Data base)

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VALIDATING DATA

• Double checking or verifying the data whether it is factual or accurate

• The assessment information must be accurate, factual and complete –

• Nursing diagnosis and interventions based on this

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DOCUMENTING DATA

• Accurate documentation is essential which include all data collected about client’s health status.

Record in a FACTUAL manner NOT interpretation • Eg. Recording the breakfast intake as – Ate 2 pieces of Bread toast , 1 egg and a cup of coffee Instead of “Good appetite”

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REPORTING - When you will Report?

• Depending on each Patient---• Disease conditions – potential problems • Family interests • Psychological upset – may lead to suicidal

attempt

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Skills require for Health Assessment

A. Cognitive skills : Assessment is a “thinking “process• Critical thinking --- why , how .. What • Clinical decision making use knowledge & experience B. Problem solving Skill – with Scientific methods- experience – “ intuition” (with experience) C. Psychomotor skills – Assessment is “doing”D. Affective/Interpersonal Skill – Assessment is “feeling” trust and mutual respectE.Ethical skills : Assessment is “ being responsible & accountable” for your practice

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Medical Assessment Vs Nursing Assessment

Assessment is the part of medical practice the process is same BUT The outcome differ • Medical assessment Diagnosis and treatment • Nursing assessment - focus on patient as a

person and reach to the optimal level of wellness(Holistic Approach)

• Both should compliment—not CONTRADICT • Nursing assessment contribute to identification of

medical problems

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Assessment is being ACCOUNTABLE & RESPONSIBLE for your practice

Assessment is DOINGAssessment

is FEELING

Assessment is

THINKING

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All