3/18/22 Rapid assessment of an individu al's airway, breathing

status, and circulation during a cardiac arrest

Assessment of suicidal tendencies or potential for
Assessment
violence
Reassessment of a client's functional health patterns
Let's talk about
in a home care or outpatient setting or, in a hospital, at
COVD
shift change
Collecting
Organizing
Nursing Assessment
Validating
o Nursing assessments focus on a client's responses
Documenting
to a health problem.
o A nursing assessment should include:
client's perceived needs
Assessing
- health problems
o Systematic and continuous collection, organization,
- related experience
validation, and documentation of data (information)
health practices
o Continuous process
- values
o All phases of the nursing process depend on the
- lifestyles
accurate and complete collection of data.

Types of Assessments
In 2008, the Joint Commission established a nursing
Type
practice guideline stating that each client should have
Initial assessment
an initial nursing assessment consisting of a history
Problem-focused assessment
and physical examination performed and documented
Emergency assessment
within 24 hours of admission as an inpatient.
Time-lapsed reassessment
The guideline states further that an LPN may gather the
Time Performed
data but the RN is responsible for care and must
Performed within specified time after admission to a
assess the data determining the needs of the client.
health care agency
The RN also has the responsibility for developing the
Ongoing process integrated with nursing care
client's plan of care.
During any physiological or psychological crisis of the
client
Data Collection
Several months after initial assessment
o is the process of gathering information about a
Purpose
client's health status.
To establish a complete database for problem
o must be both systematic and continuous to prevent
identification, refer ence, and future comparison
the omission of significant data and reflect a client's
To determine the status of a specific problem identified
changing health status.
in an earlier assessment
=
To identify life-threatening problems To identify new or
overlooked problems
Database
To compare the client's current status to baseline data
A database contains all the information about a client;
previously obtained
it includes the nursing health history, physical
Example
assessment, primary care provider's history and
Nursing admission assessment
physical examination, results of laboratory and
Hourly assessment of client's fluid intake and urinary
diagnostic tests, and materials contributed by other
output in an ICU
health personnel.
Assessment of client's ability to perform self-care
while assisting a client to bathe
Client data should include past history as well as
current problems.
The collection of data allows the nurse, client, and
health care team to identify health-related problems or
risk factors that could cause changes in a client's
health status.
Components of a Nursing Health History
Components of a Nursing Health History
o Biographic data
o Chief complaint or reason for visit
o History of present illness
o Past history
o Family history of illness
o Lifestyle
o Social data
o Psychological data
o Patterns of Health Care
Biographic Data
o Client's name, address, age, sex, marital status,
occupation, religious preference, health care financing,
and usual source of medical care.
Chief Complaint or Reason for Visit
o "What is troubling you?"
o "Describe the reason you came to the hospital or
clinic today."
The chief complaint should be recorded in the client's
own words.
History of Present Illness
- When the symptoms started
- Whether the onset of symptoms was sudden or
gradual
- How often the problem occurs
- Exact location of the distress
- Character of the complaint (e.g., intensity of pain or
quality of sputum, emesis, or discharge)
- Activity in which the client was involved when the
problem occurred
- Phenomena or symptoms associated with the chief
complaint
- Factors that aggravate or alleviate the problem
Past History
Illnesses
Immunizations and the date
Allergies to drugs, animals, insects, or other
environmental agents, the type of reaction that occurs,
and how the reaction is treated
Accidents and injuries: how, when, and where the
incident occurred, type of injury, treatment received,
and any complications
Hospitalization for serious illnesses: reasons for the
hospitalization, dates, surgery performed, course of
recovery, and any complications
Medications: all currently used prescription, over-the-
counter medications, such as aspirin, nasal spray,
vitamins, or laxatives, and herbal supplements
Family History of Illness
To ascertain risk factors for certain diseases, the ages
of siblings, parents, and grandparents and their current
state of health or, if they are deceased, the cause of
death are obtained.
Particular attention should be given to disorders such
as heart disease, cancer, diabetes, hypertension,
obesity, allergies, arthritis, tuberculosis, bleeding,
alcoholism, and any mental health disorders.
Lifestyle
Personal habits: the amount, frequency, and duration of
substance use (tobacco, alcohol, coffee, cola, tea, and
illegal or recreational drugs)
Diet: description of a typical diet on a normal day or
any special diet, number of meals and snacks per day,
who cooks and shops for food, ethnic food patterns,
and allergies
Sleep patterns: usual daily sleep/wake times,
difficulties sleeping, and remedies used for difficulties
• Activities of daily living (ADLs): any difficulties
experienced in the basic activities of eating, grooming,
dressing, elimination, and locomotion
• Instrumental ADLs: any difficulties experienced in
food preparation, shopping, transportation,
housekeeping, laundry, and ability to use the telephone,
handle finances, and manage medications
• Recreation/hobbies: exercise activity and tolerance,
hobbies and other interests, and vacations

Social Data
• Family relationships/friendships: the client's support
system in times of stress (who helps in time of need?),
what effect the client's illness has on the family, and
whether any family problems are affecting the client
• Ethnic affiliation: health customs and beliefs; cultural
practices that may affect health care and recovery
• Educational history: data about the client's highest
level of education attained and any past difficulties
with learning
Psychological Data
• Major stressors experienced and the client's
perception of them
• Usual coping pattern for a serious problem or a high
level of stress
• Communication style: ability to verbalize appropriate
emotion; nonverbal communication such as eye
movements, gestures, use of touch, and posture;
interactions with support persons; and the congruence
of nonverbal behavior and verbal expression
Patterns of Health Care
• All health care resources the client is currently using
and has used in the past.
• These include the primary care provider, specialists,
dentist, folk practitioners, health clinic, or health center;
whether the client considers the care being provided
adequate; and whether access to health care is a
problem.
Types of Data
Subjective
- symptoms - covert data
- apparent only to the person affected and can be
described or verified only by that person
Eg: Itching, pain, and feelings of worry, the client's
sensations, feelings, values, beliefs, attitudes, and
perception of personal health status and life situation.
Objective
- signs
- overt data
- are detectable by an observer or can be measured or
tested against an accepted standard
they can be seen, heard, felt, or smelled, and they are
obtained by observation or physical examination
Eg: a discoloration of the skin or a blood pressure
reading
During the physical examination, the nurse obtains
objective data to validate subjective data and to
complete the assessment phase of the nursing
process.
• Constant data is information that does not change
over time such as race or blood type.
• Variable data can change quickly, frequently, or rarely
and include such data as blood pressure, level of pain,
and age.
Examples of Subjective and Objective Data
Subjective
"I feel weak all over when I exert myself."
Client states he has a cramping pain in his abdomen.
States, "I feel sick to my stomach."
"I'm short of breath."
Wife states: "He doesn't seem so sad today." (This is
subjective and secondary source data.)
"I would like to see the chaplain before surgery."
Objective
Blood pressure 90/50 mmHg* Apical pulse 104
beats/min Skin pale and diaphoretic
Vomited 100 mL green-tinged fluid Abdomen firm and
slightly distended Active bowel sounds auscultated in
all four quadrants
Lung sounds clear bilaterally; diminished in right lower
lobe
Client cried during interview
Holding open Bible
Has small silver cross on bedside table
"Blood pressure obtained using an external cuff and
manometer may be considered secondary or indirect
data since it does not directly measure the pressure
within the arteries.
Sources of Data
o Client
O Support People
o Client Records
o Health Care Professionals
o Literature

Client
The best source of data is usually the client, unless the
client is too ill, young, or confused to communicate
clearly.
The client can provide subjective data that no one else
can offer.
If the client is hesitant to provide data, remind the
client that the privacy of all data collected is protected
and can only be shared with persons who have a
legitimate health-related need to know it.
Support People
Family members, friends, and caregivers who know the
client well often can supplement or verify information
provided by the client.
Support people are an especially important source of
data for a client who is very young, unconscious, or
confused.
Before eliciting data from support people, the nurse
should ensure that the client, if mentally able,
authorizes such input. The nurse should also indicate
on the nursing history that the data were obtained from
a support person.
Client Records
Client records include information documented by
various health care professionals.
Client records also contain data regarding the client's
occupation, religion, and marital status.
By reviewing such records before interviewing the
client, the nurse can avoid asking questions for which
answers have already been supplied. Repeated
questioning can be stressful and annoying to clients
and cause concern about the lack of communication
among health professionals.
Types of client records include medical records,
records of therapies, and laboratory records.
Healthcare Professionals
Because assessment is an ongoing process, verbal
reports from other health care professionals serve as
other potential sources of information about a client's
health.
Nurses, social workers, primary care providers, and
physiotherapists, for example, may have information
from either previous or current contact with the client.
Sharing of information among professionals is
especially important to ensure continuity of care when
clients are transferred to and from home and health
care agencies.
Literature
Standards or norms against which to compare findings
(e.g., height and weight tables, normal developmental
tasks for an age group)
Cultural and social health practices
Spiritual beliefs
Assessment data needed for specific client conditions
Nursing interventions and evaluation criteria relevant to
a client's health problems
Information about medical diagnoses, treatment, and
prognoses
Current methodologies and research findings.
Data Collection Methods
o Observing
o Interviewing - health history
O Examining - physical assessment
Observing
To observe is to gather data by using the senses.
Observing is a conscious, deliberate skill that is
developed through effort and with an organized
approach.
Observing has two aspects: (a) noticing the data and
(b) selecting, organizing, and interpreting the data.
Observing, therefore, involves distinguishing data in a
meaningful manner.
The experienced nurse is often able to attend to an
intervention and at the same time make important
observations. The beginning student must learn to
make observations and complete tasks
simultaneously.
Nursing observations must be organized so that
nothing significant is missed. Most nurses develop a
particular sequence for observing events, usually
focusing on the client first. For example, a nurse walks
into a client's room and observes, in the following
order:
1. Clinical signs of client distress (e.g., pallor or
flushing, labored breathing, and behavior indicating
pain or emotional distress)
2. Threats to the client's safety, real or anticipated (e.g.,
a lowered side rail)
3. The presence and functioning of associated
equipment (e.g., intravenous equipment and oxygen)
4. The immediate environment, including the people in
it.
Used in emergency situation
Open-ended
- Non-directive interview
- Invite clients to discover, explore, elaborate, clarify,
and illustrate thoughts/feelings
- Invites answers longer than two words
- "What" or "How"
Nurses often find it necessary to use a combination of
closed and open-ended questions throughout an
interview to accomplish the goals of the interview and
obtain needed information.

Interviewing
An interview is a planned communication or a Neutral Question
conversation with a purpose - Client can answer without direction or pressure from
In a focused interview the nurse asks the client specific the nurse
questions to collect information related to the client's - Open-ended
problem. This allows the nurse to collect information - Used in non-directive interviews
that may have previously been missed and yields more "How do you feel about that?" "What do you think let to
in depth information (D'Amico & Barbarito, 2013). the operation?"
Leading Question
Usually closed
Two Approaches - Used in directive interview
Directive - Directs the client's answer
Non-Directive - Gives client less opportunity to decide whether the
Highly structured answer is true or not
Elicits specific information "You're stressed about the surgery tomorrow, aren't
- Nurse establishes the purpose and controls the you?" "You will take your medicine, won't you?"
interview
- Limited opportunity for client to ask questions or Try to avoid asking "why" questions. These questions
discuss concerns used in an emergency situation can be perceived as a form of interrogation by the
Rapport-building interview client (Kneisl & Trigoboff, 2013).
- Nurse allows client to control the purpose, subject Because the goal of questioning is to elicit as much
matter, and pacing purposeful information as possible, anything that puts
A combination of directive and nondirective the client on the defensive will interfere with reaching
approaches is usually appropriate during the that goal.
information-gathering interview. However, in an emergency situation the use of probing
and direct questioning may be appropriate to gain a
Types of Interview Questions greater volume of data in a shorter period of time
Closed-ended (Kneisl & Trigoboff, 2013).
- Directive interview
- Restrictive
"Yes" or "No" Planning the interview and setting
- Short factual answers that provide specific Both nurses and clients are made comfortable in order
information to encourage an effective interview by balancing
-"Who," "When," "Where," "What," several factors.
"Do," "Is" o Time
o Place
o Seating Arrangement
o Distance
o Language
Time
Nurses need to plan interviews with clients when the
client is physically comfortable and free of pain, and
when interruptions by friends, family, and other health
professionals are minimal.
Place
A well-lighted, well-ventilated room that is relatively
free of noise, movements, and distractions encourages
communication.
In addition, a place where others cannot overhear or
see the client is desirable.
Seating Arrangement
Nurse can sit at a 45-degree angle to the bed when
client is in a bed
Overbed table between the client and the nurse during
initial admission interview
Two chairs placed at right angles to a desk or a few
feet apart with no table in between
Standing and looking down at a client who is in bed or
in a chair
Sitting behind a table or standing at the foot of the bed
Nurse behind a desk and the client seated across
Distance
The distance between the interviewer and interviewee
should be neither too small nor too great, because
people feel uncomfortable when talking to someone
who is too close or too far away.
Proxemics is the study of use of space.
Most people feel comfortable maintaining a distance
of 2 to 3 feet during an interview.
Some clients require more or less personal space,
depending on their cultural and personal needs.
Language
Failure to communicate in language the client can
understand is a form of discrimination. The nurse must
convert complicated medical terminology into common
English usage, and interpreters or translators are
needed if the client and the nurse do not speak the
same language or dialect
Translating medical terminology is a specialized skill
because not all persons fluent in the conversational
form of a language are familiar with anatomic or other
health terms.
If giving written documents to clients, the nurse must
determine that the client can read in his or her native
language. Live translation is preferred since the client
can then ask questions for clarification.
3/24/ 2022
Stages of an Interview
o The Opening - Introduction
o The Body - Development
o The Closing
The Opening
Sets the tone for the remainder of the interview.
The purposes of the opening are to establish rapport
and orient the interviewee.
Establishing rapport is a process of creating goodwill
and trust. It can begin with a greeting or a self-
introduction accompanied by nonverbal gestures such
as a smile, a handshake, and a friendly manner.
In orientation, the nurse explains the purpose and
nature of the interview, for example, what information
is ded, how long it will take, and what is expected of the
client. The nurse tells the client how the information
will be used and usually states that the client has the
right not to provide data.
The Body
In the body of the interview, the client communicates
what he or she thinks, feels, knows, and perceives in
response to questions from the nurse.
Effective development of the interview demands that
the nurse use communication techniques that make
both parties feel comfortable and serve the purpose of
the interview.
The Closing
The nurse terminates the interview when the needed
information has been obtained. In some cases,
however, a client terminates it, for example, when
deciding not to give any more information or when
unable to offer more information for some other
reason-fatigue, for example. The closing is important
for maintaining rapport and trust and for facilitating
future interactions.
The following techniques are commonly used to close
an interview:
1. Offer to answer questions
2. Conclude by saying "Well, that's all I need to know for
now"
3. Thank the client
4. Express concern for the person's welfare and future
5. Plan for the next meeting
6. Provide a summary to verify accuracy and
agreement
Examining
The physical examination or physical assessment is a
systematic data collection method that uses
observation to detect health problems.
To conduct the examination, the nurse uses techniques
of inspection, auscultation, palpation, and percussion
Organizing
Organizing Data
The nurse uses a written (or electronic) format that
organizes the assessment data systematically. This is
often referred to as a nursing health history, nursing
assessment, or nursing database form. The format
may be modified according to the client's physical
status.
Organizing Data
o Conceptual Models/Framework
o Non-nursing Models
o Gordon's Functional Health Pattern Framework
o Body Systems Model
o Orem's Self-Care Model
o Maslow's Hierarchy of Needs
o Developmental Theories
o Roy's Adaptation Model
o Wellness Models
Gordon's Functional Health Pattern Framework Health
Perception and Health Management
Data collection is focused on the person's perceived
level of health and well-being, and on practices for
maintaining health. Habits that may be detrimental to
health are also evaluated, including smoking and
alcohol or drug use.
Actual or potential problems related to safety and
health management may be identified as well as needs
for modifications in the home or needs for continued
care in the home.
Gordon's Functional Health Pattern Framework
Nutrition and Metabolic
Assessment is focused on the pattern of food and fluid
consumption relative to metabolic need. The adequacy
of local nutrient supplies is evaluated.
Actual or potential problems related to fluid balance,
tissue integrity, and host defenses may be identified as
well as problems with the gastrointestinal system.
Gordon's Functional Health Pattern Framework
Elimination
•Data collection is focused on excretory patterns
(bowel, bladder, skin).
•Excretory problems such as incontinence,
constipation, diarrhea, and urinary retention may be
identified.
Activity and Exercise
Assessment is focused on the activities of daily living
requiring energy expenditure, including self-care
activities, exercise, and leisure activities.
The status of major body systems involved with activity
and exercise is evaluated, including the respiratory,
cardiovascular, and musculoskeletal systems.
Gordon's Functional Health Pattern Framework
Cognitive and Perception
Assessment is focused on the ability to comprehend
and use information and on the sensory functions.
Data pertaining to neurological functions are collected
to aid this process.
Sensory experiences such as pain and altered sensory
input may be identified and further evaluated.
Sleep and Rest
Assessment is focused on the person's sleep, rest, and
relaxation practices.
Dysfunctional sleep patterns, fatigue, and responses to
sleep deprivation may be identified.

Gordon's Functional Health Pattern Framework
Cognitive and Perception
Assessment is focused on the ability to comprehend
and use information and on the sensory functions.
Data pertaining to neurological functions are collected
to aid this process.
Sensory experiences such as pain and altered sensory
input may be identified and further evaluated.
Sleep and Rest
Assessment is focused on the person's sleep, rest, and
relaxation practices.
Dysfunctional sleep patterns, fatigue, and responses to
sleep deprivation may be identified.
Gordon's Functional Health Pattern Framework
Sexuality and Reproductive Assessment is focused on
the person's satisfaction or dissatisfaction with
sexuality patterns and reproductive functions.
•Concerns with sexuality may be identified.
Coping and Stress Tolerance
•Assessment is focused on the person's perception of
stress and
on his or her coping strategies
Support systems are evaluated, and symptoms of
stress are noted.
•The effectiveness of a person's coping strategies in
terms of stress tolerance may be further evaluated.
Gordon's Functional Health Pattern Framework
Values and Beliefs
Assessment is focused on the person's values and
beliefs (including spiritual beliefs), or on the goals that
guide his or her choices or decisions.
Gordon’s
VALIDATION
Validating Data
Validation is the act of "double-checking" or verifying
data to confirm that it is accurate and factual.
Validating data helps the nurse complete these tasks:
- Ensure that assessment information is complete.
- Ensure that objective and related subjective data
agree.
Obtain additional information that may have been
overlooked.
- Differentiate between cues and inferences.
Cues are subjective or objective data that can be
directly observed Inferences are the nurse's
interpretation or conclusions made based on the cues
- Avoid jumping to conclusions and focusing in the
wrong direction to identify problems.
Not all data require validation. For example, data such
as height, weight, birth date, and most laboratory
studies that can be measured with an accurate scale
can be accepted as factual. As a rule, the nurse
validates 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.
To collect data accurately, nurses need to be aware of
their own biases, values, and beliefs and to separate
fact from inference, interpretation, and assumption
Validating Assessment Data
Guidelines
Compare subjective and objective data to verify the
client's statements with your observations.
Clarify any ambiguous or vague statements.
Be sure your data consist of cues and not inferences.
Example
Client's perceptions of "feeling hot" need to be
compared with measurement of the body temperature.
Client: "I've felt sick on and off for 6 weeks."
Nurse: "Describe what your sickness is like. Tell me
what you mean by
'on and off.""
Observation: Dry skin and reduced tissue turgor
Inference: Dehydration
Action: Collect additional data that are needed to make
the inference in the diagnosing phase. For example,
determine the client's fluid intake, amount and
appearance of urine, and blood pressure.
Observation: A resting pulse of 30 beats/min or a blood
pressure of 210/95 mmHg
Action: Repeat the measurement. Use another piece of
equipment as needed to confirm abnormalities, or ask
someone else to collect the same data.
A crying infant will have an abnormal respiratory rate
and will need quieting before accurate assessment can
be made.
Double-check data that are extremely abnormal.
Determine the presence of factors that may interfere
with accurate measurement.
Use references (textbooks, journals, research reports)
to explain phenomena.
A nurse considers tiny purple or bluish-black swollen
areas under the tongue of an older adult client to be
abnormal until reading about physical changes of
aging. Such varicosities are common.

Documenting

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).
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