MIDTERM EXAM (MSN 202)

1.) Discuss comprehensively the importance of Nursing Assessment in

Patient Care

The World Health Organisation (WHO) (2001) defines health as a state of

complete physical, mental and social well being and not merely the absence of
disease or infirmity. Whilst this is a broad definition, it implies that the nursing
approach to health care is holistic in nature and therefore health assessments
should reflect the whole person and their circumstances. Nurses are obliged to
take in to consideration a patients physical, emotional, spiritual, social and
intellectual needs when making an assessment (UK Department of Health, 2003).
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Nursing assessment includes a physical examination: the observation or

measurement of signs, which can be observed or measured, or symptoms
which can be felt by the patient. Assessment is the first part of the nursing
process, and thus forms the basis of the care plan. It is also a part of each
activity the nurse does for and with the patient.

The importance of Nursing Assessment in Nursing Care is to validate a

diagnosis, to provide basis for effective nursing care. It also helps in
effective decision making, Basis for accurate diagnosis. It promote holistic
nursing care, To provide effective and innovative nursing care, To
evaluation of nursing care.

The purpose of health assessment is to make a judgement or diagnosis because

all health treatments and decisions are based on the data gathered during
assessment. It is vital that the assessment is accurate and complete, This gathered
information provides a comprehensive description of the patient. It focuses on
the patient’s needs at that time and possible needs that may need to be
addressed in the future. It should be a fair and accurate account of the individual
and their life. Overall assessment is a way of delving deeper into a patient’s illness
and preventing more problems from arising. If inaccurate, incomplete or
inappropriate data is recorded then the overall care of the patient may be
affected, including wrong diagnosis and even the wrong treatment

2. Discuss the steps of Nursing Assessment

2.1) Data Collection
Is the process of gathering information about a client's health status. It must be
both systematic & continuous. To collect data clearly both the client & nurse must
actively participate.

Client data includes past history as well as current problems.

Types of data Subjective Data Objective data Also referred to as signs or
symptoms or covert data overt data, Can be verified described by Are
detectable by an observer only the person who or affected Can be measured
or tested Eg. Itching, pain, feelings of against an accepted standard. worry.
They can be seen, heard felt It includes the client’s or smelled and sensations,
feelings values, They are obtained by beliefs, attitudes and observation or
physical perception of personal examination health status and life For eg.
Discoloration of skin,
During Physical Examination, the nurse obtains objective data to validate
subjective data. Information supplied by family members, significant others or
health professionals are considered subjective if it is not based on fact. A
complete data base of both subjective & objective data provides a base line for
comparing the client’s responses to nursing & medical intervention.

Sources of Data Sources of data are primary or secondary. The client is the
primary source of data. Secondary or indirect sources are family members or
other support persons, other health professionals, records & reports laboratory
and diagnostic analyses, and relevant literature. All sources other than the
client are considered secondary sources. Client The best source of data
unless the client is to ill, young or confused to communicate clearly. The client
can provide subjective data that no one else can offer.
Data Collection Methods The primary methods of data collection are ◦ I.
Observing – Occurs whenever the nurse is in contact with the client or support
persons. ◦ II. Interviewing – is used while taking the nursing health History ◦ III.
Examining – Major method used in the physical health assessment.

2.2) Vaccination of Data

Validating 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 double checking or verifying the
data is accurate and
66. Purposes of data validation1. Ensure that data collection is complete2. Ensure
that objective and subjective data agree3. Obtain additional data that may have
been overlooked4. Avoid jumping to conclusion5. Differentiate cues and
inferences
67. Cues - subjective and objective data that can be directly observed by the
nurse.(What client can say, what the nurse can see, hear, feel, smell or
measure) Inferences - Nurses interpretation or conclusions made based on the
cuesExample:1. Red, swollen wound = infected wound2. Dry skin = dehydrated

2.3.)Organizing Data
The nurse uses a written or computerized format that organizes the assessment
data systematically. The format may be modified according to the client's physical
status. Example of models include Maslow's Heirarchy of Needs, the Body System
Model and Gordon's Functional Health Patterns.

2.4)Documenting Data
To complete the assessment phase, the nurse records client's data. Accurate
documentation is essential and should include all data collected about the client's
health status. Data are recorded in a factual manner and not interpreted by the
nurse.

Provides a chronological source of client assessment data and a progressive

record of assessment findings that outline the client’s course of care. • Ensures
that information about the client and family is easily accessible to members of the
health care team; provides a vehicle for communication; and prevents
fragmentation, repetition, and delays in carrying out the plan of care. •
Establishes a basis for screening or validation proposed diagnoses. • Acts as a
source of information to help diagnose new problems.

3.)Dscuss comprehensively one Nursing Model as an Assessment Tool

Nightingale's Environmental Model is a simple one, characterized by only

three major relationships:
1) Environment to patient 2) Nurse to environment 3) Nurse to patient
Nightingale’s model was developed inductivel; Major concepts are clearly
defined, and the relationships among the concepts flow logically
She focused more on physical factors than on psychological needs of
patient. Although, some of the Nightingale’s rationales have been
modified or disproved by advances in medicine and science, many of the
concepts in her theory have not only endured but have been used to provide
guidelines for nurses for more than 150 years. In particular, her model
remains relevant to illness prevention and health promotion.
NIGHTINGALE’S ENVIRONMENTAL MODEL AS A FRAMEWORK FOR
NURSING PRACTICE Nightingale expected nurses to use their skills of
observation in caring the patients. Nursing observations and
documentation should focus on the assessment of the patient in relation the
13 canons identified by Nightingale when nursing care is provided that is
framed by Nightingale’s environment model.

NIGHTINGALE’S THIRTEEN CANONS 1. Ventilation and warmth 2. Health of houses

3. Petty management 4. Noise 5. Variety 6. Food intake 7. Food 8. Bed and
bedding 9. Light 10. Cleanliness of rooms/walls 11. Personal cleanliness 12.
Chattering hopes and advices 13. Observation of the sick
10. 1. VENTILATION AND WARMTH: Keeping patient, patient’s room warm
Keeping patient’s room well ventilated and free of odors. Keep the air within as
pure as the air external air/without noxious smells.
11. 2. HEALTH OF HOUSES: This canon includes five essentials of- Pure air, Pure
water, Efficient drainage, Cleanliness, Light Examples include: removing
garbage or standing water ensuring clean air and water and free from odour
and that there is plenty of light.
12. 3. PETTY MANAGEMENT: Continuity of the care, when the nurse is absent
Documentation of the plan of care and all evaluation will ensure others give
the same care to the client in your absence.
13. 4. NOISE: Avoidance of sudden/startling noises. Keeping noise in general
to a minimum. Refrain from whispering outside the door.
14. 5. VARIETY: Provide variety in the patient’s room to help him/her avoid
boredom and depression. This is accomplished by cards, flowers, pictures,
books or puzzles (presently known as diversional therapy) Encourage
significant others to engage with the client.
15. 6. FOOD INTAKE: Assess the diet of the client. Documentation of
amount of foods and liquids ingested at every meal.
16. 7. FOOD: Instructions include trying to include patient’s food preferences.
Attempt to ensure that the client always has some food or drink available that
he/she enjoys.
17. 8. BED AND BEDDING: Comfort measures related to keeping the bed dry,
wrinkle-free and at the lowest height to ensure the client’s comfort.
18. 9. LIGHT: Assess the room for adequate light. Sunlight works best.
Develop and implement adequate light without placing the client in direct light.
19. 10. CLEANLINESS OF ROOMS/WALLS: Assess the room for dampness,
darkness and dust or mildew. Keeping the environment clean (free from dust,
dirt, mildew and dampness)
20. 11. PERSONAL CLEANLINESS: Keeping the patient clean and dry at all times
Frequent assessment of client’s skin is needed to maintain adequate moisture.
21. 12. CHATTERING HOPES AND ADVICES: Avoidance of talking without reason
or giving advice that is without fact. Continue to talk to the client as a person.
And to stimulate the client’s mind Avoid personal talks.
22. 13. OBSERVATION OF THE SICK: Making and documenting observations.
Continue to observe the client’s surrounding environment.