JOSCO COLLEGE OF NURSING EDAPPONE PANDALAM

SEMINAR ON HEALTH ILLNESS PROBLEMS HEALTH

BEHAVIOURS AND METHODS OF DATA COLLECTION

SUBMITTED TO: SUBMITTED BY:

MRS:RINCY MRS:RAKHI R NAIR
LECTURER 1 ST YEAR MSC NURSING
JOSCO COLLEGE OF NURSING JOSCO COLLEGE OF NURSING
EDAPPON EDAPPON

SUBMITTED ON : 13.11.13
INTRODUCTION

A nurse follows nursing process to organize and follow nursing care. Use of the process
allows the nurse to integrate elements of critical thinking to make judgments and to take
actions based on reason. The nursing process is used to identify diagnose and treat
human responses to health and illness. The process includes five steps. Assessment,
nursing diagnosis, planning implementation and evaluation

Assessing is the systematic and continuous collection validation and

communication of patient data. These data reflex how health functioning is enhanced by
health promotion or compromised by illness or injury

DEFINITION

HEALTH

Health is a state of complete physical mental and social wellbeing and not merely an
absence of disease or infirmity

ILLNESS

It is a state in which a person’s physical emotional intellectual social developmental or

spiritual functioning is diminished or impaired compared with previous experience

ASSESSMENT

It is the deliberate and systematic collection of data to determine client’s current and
past health status and to determine the current and past coping patterns

Every health care professional perform performs assessment to make professional

judgments related to his or her client. However the purpose of nursing history and
physical examination differs greatly from that of medical or other type of examinations

ELEMENTS OF ASSESMENT

 Data collection
 Data validation
 Data interpretation
 Data clustering
 Data documentation

PURPOSE OF NURSING ASSESSMENT

To establish a data base concerning a clients physical psychological and

emotional health inorder to identify health promoting behaviors as well as actual and or
potential health problems

Nursing health history

Physical assessment
Result of diagnostic and laboratory test
Material from other health personnel
TYPES OF ASSESSMENT

INITIAL COMPREHENSIVE ASSESSMENT

An initial assessment is also called an admission assessment and is performed when the
client enters the health care from a health care agency. The purpose is to evaluate the
client’s health status to identify the functional health patterns that are problematic and
to provide an indepth comprehensive data base which is critical for evaluating changes
in the client’s health status in subsequent assessments.

PROBLEM FOCUSED ASSESSMENT

A problem focused assessment collects data about health problem that has already
been identified. This type of assessment has a narrower scope and shorter time frame
than the initial assessment. In focus assessments the nurse determines whether the
problems still exist and whether the status of problem has changed. This assessment
also includes the appraisal of any new overlooked or misdiagnosed problems. Intensive
care units may perform focus assessments every few minutes.

EMERGENCY ASSESSMENT

Emergency assessment takes place in life threatening situations in which the

preservation of life is the top priority. Time is of the essence in rapid identification of and
interventions for the client’s health problems. Often the client’s difficulties involve airway
breathing and circulatory problems. Abrupt changes in self concept or roles or
relationship also can initiate an emergency. Emergency assessment focus on few
essential health patterns and is not comprehensive

TIME LAPSED OR ON GOING ASSESSMENT

Time lapsed reassessment is another type of assessment takes place after the initial
assessment to evaluate any changes in the client’s functional health. Nurse perform time
lapsed reassessment when substantial period of time has elapsed between assessment

STEPS OF ASSESSMENT

Collection of data
Validation of data
Organization of data
Recording and documentation of data

COLLECTION OF DATA

Gathering information about the client includes

Physical, psychological, social, emotional, cultural, spiritual factors that
may affect clients health status
Past health history of client
Current and present health problems of the client

TYPES OF DATA

a) SUBJECTIVE DATA -
  also referred to as symptoms or cessations’.
 Information from the clients point of view is described by persons
experiencing it.
 Information supplied by family members , significant others, other health
professionals are considered as subjective data
b) OBJECTIVE DATA
 Also referred to as sign
 Those that can be detected or measured using accepted standards or norm
 Mainly collected by general observation and by using the four physical
examination techniques: inspection , percussion, palpation, auscultation

SOURCES OF DATTA COLLCETION

 Primary source - data directly gathered from the client using interview and
physical examination
 Secondary source- data gathered from clients family members significant others
clients medical records chart other members of the health team and related care
literature journals

METHODS OF DATA COLLECTION

INTERVIEW

It is a planned purposeful conversation and communication with the client to get

information identify problems evaluate change to teach or to provide support or
counseling. Interview consists of asking questions designed to elicit subjective data from
the client or family members.

PHASES OF INTERVIEW

 Preparatory phase
 Introduction
 Working phase
 Termination

PREPARATORY PHASE

Before initiating the interview the nurse prepares to meet the patient by reading current
and past records and reports available. It is important to let know ones stereotypes and
prejudice affects the nurse patient relationship

During this phase the nurse should ensure that the

enviournment in which the interview is to be conducted is private and relaxed. The
interview should be scheduled when both nurse and patient are free of concerns and
distractions so that they are concentrate on the task

INTRODUCTION

The interview introduction is crucial because it sets the tone not only for the remainder
of the interview but also for the every following nurse patient interaction. At the end of
this phase of interview the patient should know the name of the primary nurse and what
he or she can expect of nursing care should sense that the nurse is competent and cares
about him or her and should know what is expected of him or her in terms of developing
the plan of care and participating in its execution.

WORKING PHASE

During the working phase the nurse gathers information about the clients past and
present health status. The nurse should begin the interview with current complaint or
concern and proceed according to the identified format. The nurse should use
communication skill during the interview that include both verbal and non verbal
techniques that facilitate the acquisition of the data base

VERBAL TECHNIQUE

Verbal communication during the interview process requires a conscious effort on the
part of the nurse. During the interview the nurse uses two types of questioning methods.
Open ended and closed ended questions

OPEN ENDED QUESTIONS – the nurse uses open ended questions to elicit information
from the client about the feelings concerns opinions and perceptions and to allow for the
validation of both subjective and objective data

CLOSED QUESTIONS – They are questions that can be answered briefly or with one word
response

REFLEXION

This is another verbal technique. Reflexion of feelings involves informing the client about
the feelings that the nurse perceives the client is having. This is done to assist the client
in focusing on these feelings and making him or her more aware of them

NON VERBAL TECHNIQUES

A variety of non verbal techniques can hinder or facilitate the communication processes
and its effect on the nurse patient relationship. Non verbal technique involves a variety
of body language, manures, including gestures, facial expressions, body positions, tone
of voice, use of touch, appearance and active listening

TERMINATION

The interview concludes when the data base is obtained or when the nurse determines
that the client is not able to continue. Informing the client that the interview will be
ending shortly, preparing the client for conclusion. At this point no new material should
be introduced by the nurse

OBSERVATION

It is used to gather the information using the five senses and instruments

PHYSICAL EXAMINATIONS
Systemic data collections to detect health problems using unit of measurements physical
examination technique and interpretation of laboratory results the assessment can be
done by cephalocodal approach or body system approach

TECHNIQUES

INSPECTION

It is the visual examination of the client

GUIDELINES FOR EFFECTIVE INSPECTION

 Be systematic
 Fully expose the area to be inspected and cover the other parts
 Use good light preferably natural light
 Maintain comfortable room temperature
 Observe color symmetry and shape of movement
 Compare bilateral structures for similarities and differences

PALPATION

Palpation uses the sense of touch to assess various parts of the body and helps to
confirm findings that are noted on inspection. The hands especially the finger tips are
used to assess skin temperature, to check pulse texture moisture etc

TYPES OF PALPATION

LIGHT PALPATION – to check muscle tone and assess for tenderness

DEEP PALPATION – to identify abdominal organs and abdominal mass

PERCUSSION

Percussion is the striking of the body surface with short sharp strokes inorder to produce
palpate vibrations and characteristics sound. It is used to determine the location size and
density of the underlying structures to determine the presence of air or fluid in a body
surface and to elicit tenderness

Types of percussion

Direct percussion – percussion in which one hand is used and the striking finger of the
examiner touches the surface being percussed

INDIRECT PERCUSSION – percussion in which two hands are used and the plexer strikes
the finger of the examiners other hand which is in contact with the body surface being
percussed

BLUNT PERCUSSION – percussion in which the ulnar surface of the hand or fist is used in
place of the fingers to strike the body surface either directly or indirectly

AUSCULTATION

Auscultation is listening to the sounds produced inside the body. These include breath
sounds, heart sounds, vascular sounds and bowel sounds. It is used to detect the
presence of normal and abnormal sounds and to assess them in terms of loudness, pitch,
quality, frequency and duration

COMPONENS OF NURSING HISTORY TAKING

Biographic data – Name, address, age, marital status, occupation, religion

Reason for visit – chief complaints: primary reason why client seeks consultation or
hospitalization

History of present illness – includes usual health status, chronological story, family
history, disability assessment

Past health history – includes all previous immunizations and experiences with illness

Family history – reveals risk factors for certain diseases

Review of systems – review of all health problems by body systems

Life styles – includes personal habits, diet sleep or rest patterns, activity of daily living,
recreation and hobbies

Social data – include family relationship ethnic and educational background economic
status home and neibourhood conditions

Psychological data – information about clients emotional state

Pattern of health care – includes all health care resources hospitals clinics health centers
family doctors

VALIDATION OF DATA

The act of double checking or verifying data to confirm that it is accurate and complete.
Validation of data is the process of confirming and verifying that the subjective and
objective data collected are reliable and accurate

STEPS IN VALIDATION

 Deciding whether the data require validation

 Determining the ways to validate the data
 Identifying the areas where the data are missing

PURPOSE OF DATA VALIDATION

 Ensure the data collection is simple

 Ensure that objective and subjective data agree
 Obtain additional data that may have been overlooked
 Avoid jumping to conclusions
 Differentiate clues and inferences

METHODS OF VALIDATION

 Recheck your own data with repeated assessments

 Clarify data with the client by asking additional questions
  Verify the data with another health care personnel
 Compare your objective findings with subjective findings to uncover discrepancies

ORGANIZATIION OF DATA

It uses a written or computerized format that organizes assessment data systematically

COMMUNICATE RECORD AND DOCUMENT DATA

 Nurses record all data collected about clients health status

 Data are recorded on a factual manner not as interpreted by the nurse
 Recording subjective data in clients word, restating in other words what the client
says might change its original meaning

PURPOSE OF DOCUMENTATION

 Provides a chronological source of clients assessment data and a progressive

record of clients assessment findings that outline the clients course of care
 Ensure that the information about the client and family is easily accessible to
members of health care team
 Establishes a basis for screening and validation proposed diagnosis
 Acts as a source of information to help diagnosis
 Provides access to significant epidemiological data for future investigations
research and educational endeavors

GUIDELINES FOR DOCUMENTATION

 Document legibly or print neatly in unerasable ink

 Use correct grammar and spelling
 Avoid wordiness that creates rudency
 Avoid recording the word normal for normal findings
 Record complete information and details for the clients symptoms or experiences
 Include additional assessment content when applicable
 Use phrases instead of sentences to record data

COMMON PROBLEMS OF DATA COLLECTION

 Irrelevant or duplicate data collected

 Erroneous or misinterpreted data collected
 Too little data acquired from the client
 Poor documentation from staff
 Conflicting data
 Language barrier
 Insufficient time
 Lack of equipment

SUMMARY

In this topic we have discussed about identification of health Illness problems, definition
of assessment types of assessment, steps of assessment sources of data methods of
data collection components of nursing history and problems of data collection
CONCLUSION

The nursing process applied to the care of all client systems including individual’s
families groups or communities. Use of the process allows the nurse to differentiate their
practice from that of physicians and other health care professionals. When nurses think
critically the client becomes an active participant and the ultimate outcome is a
comprehensive individualized approach to care

RESEARCH ABSTRACT

 A study was conducted to test the efficacy of structured symptom assessment on

level and rate of change in symptom distress over time on Outpatient oncology
offices and clinics in California. 48 subjects newly diagnosed with advanced lung
cancer, predominantly non-small cell was selected. Most subjects received
chemotherapy, 50% were women, and their average age was 62 years. 190
observations were analyzed. . Both groups completed the Symptom Distress Scale
(SDS) monthly. After bivariate screening of potential predictors, a multivariate
regression model for level and rate of change in SDS scores was created. And they
found that Systematic use of structured symptom assessment forestalled
increased symptom distress over time. Chemotherapy lessened symptom distress,
but the impact diminished with time. Subjects with more depression and greater
functional limitations had greater symptom distress.
 Nursing pain assessments are influenced by the length of available tools, patient
characteristics, patient pathology, concern about addictive behavior, and
characteristics of the nurse. The relationship among these variables was explored
in a sample of community hospital nurses (N = 59) and ONS members (N = 19).
Although a number of interesting similarities were found in the two groups, age,
professional and continuing education, and care setting appear to be related to
differences in pain assessment practices. Implications for practice, research, and
education include teaching nurses to: assess factors related to quality of life in the
pain experience, assess and validate data from families, assess coping skills, and
teach patients to use behavioral pain management strategies. The findings also
suggest that further study is needed concerning the relationship between personal
beliefs and experiences and the assessment and management of pain.
Membership in professional organizations appears to be associated with
comprehensive approaches to the assessment and management of cancer and
pain should be addressed in further research.
BIBILIOGRAPHY

 B T BASAVANTHAPPA,”Fundamentals Of Nursing”, first edition, Jaypee publishers;

page no:200-210
 HELENHARKAREADER MARY ANN HOGAN, “Fundamentals of nursing”, second
edition, Saunders publishers, page no:92-104
 POTTER PERRY,” Fundamentals of nursing”, sixth edition, Mosby Publishers, page
no:278-294
 SHABEER P BASHEER. S YASEEN KHAN,”A Concise Text Book Of Advanced nursing
Practice”, EMMENSE Publishers page no:504-510
 WILSON GIDDENS,” Health Assessment For Nursing Practice” ,fourth edition Mosby
Publishers, page no:14-12

JOURNAL

 INDIAN JOURNAL OF HOLISTIC NURSING volume 5 , September 2009, page no:29

 THE NURSE INTERNATIONAL volume 2, number 3, May June 2010, page no:14-15

INTERNET

 www.google.co.in/url?sa=t$rit=j$q
 En.wikipedia.org/wiki/nursing process