NURSING

ASSESSMENT
PROCESS.
⦿ Pema, a 17 yr. old has just arrived back in
united states after her visit to her family in
kerala. She comes to ER because she woke up
that morning with flu like symptom (cough,
sore throat, fever, muscle ache, fatigue). “I
am scares because of everything I’ve seen
television and read news paper about new
virus.”
OBJECTIVE
⦿ Describe purpose of nursing assessment.
⦿ Identify three main steps of assessment
⦿ Differentiate subjective and objective data
and primary and secondary data
⦿ Identify three method of data collection and
how each is useful
⦿ Describe important aspect of interview.
What do you understand
by nursing assessment?

What are assessment

you have done in past
clinical posting?
NURSING ASSESSMENT
⦿ “Systematic, and continuous collection,
validation, and documentation of data.

⦿ Assessment is process of collecting

data(information) to identify actual or
potential health problem and strength of
patient.

Nursing unique assessment focuses on

client/pt. response to health problem rather
than pathologic condition of disease.
PURPOSE.
⦿ To establish a database to identify health
related problem or risk factor and strength of
patient.
⦿ To plan and deliver effective individualized
holistic nursing care.
⦿ To build effective nurse patient relationship.
⦿ To determine patient’s progress or
deterioration of health status.
TYPES OF ASSESSMENT.
⦿ Initial/comprehensive assessment.
⦿ Problem focused assessment.
⦿ Emergency assessment.
⦿ Time-lapsed/ ongoing assessment.
STEPS/ELEMENT IN NURSING
ASSESSMENT.

1. Collecting and organizing data.

2. Validating data.
3. Documenting data.
PREPARING FOR DATA
COLLECTION.
⦿ Establishing assessment priorities: thinking
priory about type of data needed to develop
NCP or which type of data/how much data
would you collect to meet purpose of nursing
assessment.

⦿ Structuring/organizing the assessment.

Using systematic structure or guideline,
specifically developed for nursing assessment
to ensure comprehensive, holistic data are
collected.(Gordon's 11 functional pattern)
1.DATA COLLECTION.
⦿ Data collection is the “Process of gathering
information about a client’s health status”
⦿ Data collection must be both systematic and
continuous :to prevent the omission of
significant data and reflect a client’s
changing health status.
⦿ Database should include all the information
of pt.(history taking, gordons health pattern,
physical examination, lab and diagnostic test
and doctor notes.
⦿ It should begin when the pt enters the health
care system.
DATA COLLECTION.
1.Types of data.
subjective

objective

2:Sources of data. Primary(pt.)

secondary(other
profession, records and reports, support
person, laboratory and diagnostic analysis)
SUBJECTIVE DATA
⦿ Subjective data also referred as …………… are
statement, feelings, perceptions or concern
communicated by pt.

⦿ For ex:…………………………….
COLLECTING SUBJECTIVE DATA

⦿Major areas of subjective data include:

- Biographical information(name, age, religion,
occupation)
- chief complaint.
- Past health history,
- Family history
- Health and lifestyle practices
The nurse should use effective communication skills to
be able to collect good data
OBJECTIVES DATA

Objective data also referred as ……………….,

can be observed, measured or felt by
someone other than person experiencing
them.
These data include:
- Physical characteristic (e.g. skin colour,
posture)
- Body functions (e.g. heart rate and
respiratory)
- Appearance (e.g. dress and hygiene)
- Behaviour (e.g. speech, behavior, affect)
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METHOD OF DATA
COLLECTION.

1: Observing.

2: Interviewing.(history taking)

3: Physical Examination.
OBSERVATION.
⦿ To observe is method of gathering data by
using four sense.
⦿ It has two aspect: a)noticing the data and
b)Interpretating the data.
 INTERVIEW.
⦿ A formal meeting in which somebody is
asked question to see if they are
suitable for job, course of study
⦿ Nursing interview is planned
communication or conversation with a
purpose.
1: Establishing rapport and build a
NPR.
2: Gathering holistic information of
pt to identify deviation that can be
treated with nurse-patient
collaboration.
COMMUNICATION DURING THE
INTERVIEW.
▪ Communication means exchange of ideas,
opinions, facts and information between two
persons or group in such a way that the meaning
received is equivalent to those that is perceived
and understood by the sender.
⦿ Client during interview involves two types of
communication.
1: verbal and nonverbal communication.
COMMUNICATION DURING THE
INTERVIEW.
⦿ Use of words, spoken ⦿ Through gesture or
behaviour that do not
or written. involve spoken or
written.
⦿ Eg: facial expression,
tone and pitch of the
voice, gesture, space,
physical
appearance,posture and
touch.
⦿ It gives more meaning
to verbal
communication.

verbal Non-verbal
TYPE OF
COMMUNICATION(PURPOSE)
⦿ Interpersonal ⦿ Casual conversation ,
interaction between spontaneous and with
nurse and patient no planned agenda.
focusing on patient’s ⦿ It is not a goal
need to promote an oriented.
effective exchange of
information.
⦿ It is purposeful,
goal-oriented, pt
focused, and planned. Non-therapeutic
communication/social
Therapeutic communication communication.
THERAPEUTIC COMMUNICATION
TECHNIQUE.
1 Active listening.(Soler) 8 Informing.

2 Conveying acceptance 9 Humor

3 Silence. 10 Focusing

4 Using open ended question. 11 Providing lead to patient.

5 Re-stating/paraphasing. 12 Suggesting.

6 Clarification. 13 Summarizing

7 Reflection
NON THERAPEUTIC TECHNIQUE.
⦿ challenging,
⦿ probing,
⦿ changing the subject,
⦿ defensiveness,
⦿ false reassurances,
⦿ disagreeing,
⦿ judgments,
⦿ rejection and minimization,
⦿ stereotyping.
WHAT TO AVOID DURING
INTERVIEW?
⦿ Avoid biased or ⦿ Excessive or
leading question. insufficient eye
⦿ Rushing through the contact.
interview. ⦿ Distraction and
⦿ Reading the question distance.
⦿ Standing.

Verbal communication Non-verbal communication

PHASES OF INTERVIEW
Pre-introductory phase.

Introductory phase.

Working phase.

Summary or closing phase/termination phase

PRE-INTRODUCTORY PHASE.
⦿ It begins when a nurse is assigned a patient.
⦿ Task involves:
1:Explore owns feeling, strength and
limitation.
2:Review data before meeting with pt. or
collect data whenever possible.
INTRODUCTORY PHASE.

⦿ Nurse and pt. meet for first time.

⦿ Task involves:
1: establish rapport, trust and
acceptance.(therapeutic
communication technique)
2: explain purpose of interview.
3: assure about maintaining
confidentiality.
4: taking consent.
WORKING PHASE.
⦿ Therapeutic work is carried out.
⦿ Gather major data, reason for seeking care or
chief complaint, history of present illness, past
health history, family history, review of body
system.
⦿ Listen, observes cues, and validate information,
and collaboratively identify pt.'s
problem and goal.
SUMMARY AND CLOSING PHASE.
⦿ After gathering all the information.
⦿ Summarize information obtained during working
phase and validate the problem and goal with
patient.
⦿ Discuss about possible plan to resolve problem.
⦿ Make sure to ask if anything else concerns the pt.
SPECIAL CONSIDERATION DURING
THE INTERVIEW.
⦿ Three variable should be considered during
interviewing:
1: Gerontology variation.(hearing acuity, trust
buildup, showing concern, simple term,
respect)
2: Culture variation.(language, non-verbal
technique,
3: Emotional
variation.(fear,anxiety,angry,depressed)
BARRIER TO THERAPEUTIC
COMMUNICATION.
⦿ Language difference
⦿ Gender.
⦿ Health status.
⦿ Environment
⦿ Developmental level.
⦿ Sociocultural difference
⦿ Emotion
⦿ Perceptual
3. EXAMINATION/NURSING
PHYSICAL ASSESSMENT..
⦿ “Systemic data collection of objective
information using sense of sight, hearing,
smell and touch to detect health problem
by using four physical assessment
technique ”
(Inspection, Auscultation,Palpation, and
Percussion.)
PURPOSE OF NURSING PHYSICAL
EXAMINATION/ASSESSMENT
1. Collect data of present health status.

2. Identify health problem.

3. Establish a database for intervention.

4. Validation and clarification of any

subjective complaint.
CHARACTERISTIC OF DATA
⦿ Purposeful: identify the purpose of nursing
assessment and gather data appropriately.
⦿ Complete: as much as possible, collect all
the data needed to understand pt health
problem and to develop a plan of care to
maximize health and well being.
⦿ Factual and accurate: it should be reliable,
validated and interpreted based on fact, not
on assumption, or stereotyping.
⦿ Relevant:type of data and amount of data
collection should be determined to prevent
endless task.
PROBLEMS R/T DATA COLLECTION.
⦿ Database inappropriately organized.
⦿ Pertinent data omitted.
⦿ Irrelevant/duplicate data collected.
⦿ Misinterpreted data collection.
⦿ Failure to establish rapport.
⦿ Failure to update data base.
2. ORGANIZING DATA.
⦿ collected data need to be structured or
organized systematically to assess emerging
pattern.
⦿ Data are often organized based on selected
nursing model.
⦿ In our manual book it is organized as ………
3. VALIDATING DATA.
⦿ Validation is the act of “double-checking” or
verifying data to confirm that it is accurate
and factual.
⦿ “Confirming or verifying”.
⦿ For eg: you checked pt’s bp and found
180/90mm/hg. “is it valid ?” double check it
after 15 minute. “Is it reliable?”checking bp
with other instrument.
PURPOSE OF VALIDATING
DATA.
1. Ensure that assessment information is
complete.
2. Ensure that objective and related
subjective data agree.
3. Obtain additional information that may
have been overlooked.
4. Differentiate between cues and inferences.
5. Avoid jumping to conclusions and focusing
in the wrong direction to identify problems
IDENTIFYING DATA TO BE
VALIDATED.
⦿ validate data when there are discrepancies
between data obtained in the nursing
interview (subjective data) and the physical
examination (objective data), or when the
client’s statements differ at different times
in the assessment.
⦿ For example “a nurse seeing a man holding
his arm to his chest might assume that he is
experiencing chest pain,but the nurse should
ask the client why he is holding his arm to his
chest. The client’s response may validate the
nurse’s assumptions or prompt further
questioning.”
HOW YOU CAN VALIDATE YOUR
INFERENCE?
⦿ Physical examination and expert
confirmation.
⦿ Clarifying the statement.(acute and chronic
meaning)
⦿ Sharing your inferences with other member
of team.
⦿ Comparing cues to knowledge base of normal
function.
⦿ Checking your finding with textbook, journal.
⦿ Checking consistency of cue.
refer fig 12-6 page 238(taylor)
3.DOCUMENTING DATA.

⦿ To complete the assessment phase, the nurse

records client 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.
⦿ For example, the nurse records the client’s
breakfast intake (objective data) as “coffee 240
mL, juice 120 mL,1 egg, and 1 slice of toast,”
rather than as “appetite good” (a judgment).
3.DOCUMENTING DATA.

⦿ A judgment or conclusion such as “appetite

good” or “normal appetite”may have
different meanings for different people.
⦿ To increase accuracy, the nurse records
subjective data in the client’s own words,
using quotation marks. Restating in other
words what someone says increases the
chance of changing the original meaning
⦿ Initial data should be documented as soon as
possible and if any important data cannot be
obtained during initial assessment, needs to
documented so that you can be obtain as
soon as possible.
⦿ Objective and subjective data should be
summarized and written under appropriate
marked heading, using pt’s own word’s and
avoid words such as “adequate, good,
average, normal, poor, small, large”.
 NURSING PROCESS CHART/FORM
assessment

Subjective
data: pt said
“I am having
breathing
difficulty”
Objective
data:respirato
ry rate:
10b/min
Cynosed over
lips.
Spo2: 70%
Lemo is a pregnant 29-year-old married woman,
gravida 1, para 0. She is having contractions 5 minutes
apart, which she describes as
“severe cramps.” Her husband states, “I think her
water broke on the way to the hospital.”

Physical examination reveals that Mrs. Lemo is 6 cm

dilated. Fetal monitor reveals a fetal heart rate of 120
beats per minute (BPM). The patient’s vital signs
include BP 140/80, pulse 90 BPM, respirations 22/min.
Prenatal records reveal hemoglobin12.0, hematocrit
45, and blood type AB.

Identify:
• Primary data source
• Secondary data source
• Subjective data
• Objective data
Primary data source:
Lemo
• Secondary data source
Husband and Prenatal records
• Subjective data:
She is having contractions
5 minutes apart, which she describes as
“severe cramps.”
• Objective data:
Mrs. Lemo
is 6 cm dilated. Fetal monitor reveals a fetal heart
rate of 120 beats per minute (BPM). The patient’s
vital signs include BP 140/80, pulse 90 BPM, respirations
22/min. Prenatal records reveal hemoglobin12.0,
hematocrit 45, and blood type AB.
TEST YOUR KNOWLEDGE
Which of the following ⦿ A major characteristic of
elements is best categorized the nursing process is
as secondary subjective data? which of the following?
⦿ 1. The nurse measures a
weight loss of 10 pounds ⦿ 1. A focus on client needs
since the last clinic visit.
⦿ 2. Its static nature
⦿ 2. Spouse states the client
has lost all appetite. ⦿ 3. An emphasis on
physiology and illness
⦿ 3. The nurse palpates
edema in lower ⦿ 4. Its exclusive use by and
extremities. with nurses
⦿ 4. Client states severe pain
when walking up stairs.
TEST YOUR KNOWLEDGE
although nursing process
is presented as orderly
progression of steps, in
reality there is interaction
and overlapping among 5
stpes.which of the
following describes this
characteristics of nursing
process?
1: systematic.
2:Dynamic.
3: interpersonal.
4: outcome oriented.
Q: In the validating
activity of the assessing
phase of the nursing
process, the nurse
performs which of the
following?
⦿ 1. Collects subjective
data.
⦿ 2. Applies a framework
to the collected data.
⦿ 3. Confirms data are
complete and accurate.
⦿ 4. Records data in the
client record.