ASSESSING

Collecting data . Organize data. Validate data. Document data

ASSESSING
• Assessing is the systematic and continuous collection,
organization, validation and documentation of data
• All phases of nursing process depend on the accurate and
complete collection of data
 TYPES OF ASSESSMENT
Initial- nursing assessment- performed within Problem- focused assessment- ongoing process

specified time after admission to a health care integrated with nursing care
Purpose:
agency.
To determine the status of a specific problem
Purpose:
identified in an earlier assessment
To establish a complete database for
Example:
problem identification, reference, and
Hourly assessment of client’s fluid intake and
future comparison.
urinary output in an ICU.
Example:
Assessment of client’s ability to perform self-
Nursing admission assessment
care while assisting a client to bathe.
 TYPES OF ASSESSMENT
Emergency assessment- during any
physiological or psychological crisis of the client
Purpose:
To identify life- threatening problems.
To identify new or overlooked
problems.
Example:
Rapid assessment of an individual’s
airway, breathing status, and circulation
during cardiac arrest
Assessment of suicidal tendencies or
potential for violence.
Time- lapsed assessment- several months after
initial assessment
Purpose:
To compare the client’s current status
to baseline date previously obtained
Example:
Reassessment of a client’s functional
health patterns in a home care or
outpatient setting or, in a hospital, at
shift change.
 STEPS OF ASSESSMENT

Collecting of data Validating of data

Organization of data Documenting data

Collecting of data
• It is the process of gathering information about a client’s health status.
• It must be:

Systemic and continuous to prevent the omission of significant data and

reflect a client’s changing health status.
 Types of data Objective data
Subjective data  Referred to as signs or overt data
 Referred to as symptoms or covert data  Are detectable by an observer or can be
 Are apparent only to the person affected and measured or tested against an accepted
can be described or verified only by that standard.
person.  They can be seen, heard, felt, or smelled,
 It includes the client’s sensations, feelings, and they are obtained by observation or
values, beliefs, attitudes, and perception of physical examination.
health status and life.  Example:
 Example: Itching, pain, and feelings of worry. Discoloration of skin
Blood pressure reading
 Types of data Objective data
 Referred to as signs or overt data
Subjective data
 Are detectable by an observer or can be
 Referred to as symptoms or covert data
measured or tested against an accepted
 Are apparent only to the person affected and
standard.
can be described or verified only by that
 They can be seen, heard, felt, or smelled,
person.
and they are obtained by observation or
 It includes the client’s sensations, feelings,
physical examination.
values, beliefs, attitudes, and perception of
 Example:
health status and life.
Discoloration of skin
 Example: Itching, pain, and feelings of worry.
Blood pressure reading
 Sources of data
Client – the best source of data is usually the client, unless the client is too ill, young or confused
to communicate clearly.
Support people – Family members , friends, and care givers who knows the client well often can
supplement or verify information provided by the client.
Client records –information documented by various health care professionals.
Healthcare Professionals – verbal reports from other healthcare professionals serve as other
potential sources of information about the client health.
Literature- the review of nursing and related literature, such as professional journals and
references texts, can provide additional information for the data base.
 Method of Data Collection
Observing
- is a conscious, deliberate skill that is
developed through effort and with an
organized approach.
Example: Using the senses to observe client
data
Methods of observation
a. Vision- physical appearance, gait,
movement, coloration, skin integrity,
moisture, dryness, edema, facial
expressions and posture.
b. Smell- body and breath odors, body
elimination.
c. Hearing- infliction of voice,
wheezing, coughing, crying,
cardiopulmonary and abdominal
sounds.
d. Touch- skin temperature, moisture,
edema, discomfort, abnormal
growths.
 Method of Data Collection

Interviewing
- is a planned communication or conversation with a
Two Approaches of an Interview
purpose. a. Directive interview- is highly structured
and elicits specific information.
b. Nondirective interview- or rapport
Example: Nursing health history
building interview the nurse allows the
client to control the purpose, subject matter,
and pacing.
 Types of Interview Questions
Closed questions- restrictive and generally require
only “yes” or “no” or short factual answers that
provide specific information.
Example: Are you having pain now?
Neutral questions- client can answer without
direction or pressure from the nurse, is open
ended, and is used in nondirective interviews.
Example: How do you feel about that?
Open- ended question- it specifies only
the broad topic to be discussed, and invites
longer than one or two words.
Example: What brought you to
hospital?
Leading question- is usually closed, used
in a directive interview and thus directs
the client’s answer.
Example: You are stressed about
surgery tomorrow, aren’t you?
Method of Data Collection

Examining- is a systematic data collection method that uses

observation to detect health problems.
To conduct the examination, the nurse uses techniques of:
a. Inspection
b. Palpation
c. Percussion
d. Auscultation
Physical examination can be:
e. Cephalocaudal approach
f. Screening examination and Review of systems
ORGANIZING DATA
The nurse uses a written (or electronic) format
that organizes the assessment data
systematically.
 Conceptual Models/Framework
Nursing models or framework
 Gordon’s functional health pattern framework
 Orem’s self-care model
 Roy’s adaptation model
 Wellness models
Non nursing models
 Body systems model
 Maslow’s hierarchy of needs
 Developmental theories
 VALIDATING DATA
Is act of “double checking” or verifying the data to
confirm that it is accurate and factual.
 DOCUMENTING DATA
 Assessment data must be recorded and reported
 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.
Quiz
1-2. Types of Data
3. Primary source of Data
4-6. secondary sources of data
7. Using the senses to observe client data
8-9. Two approaches of an interview
10. The act of double checking or verifying
Group 1 Members:
Nasinopa, Ronald Ehron T.
Mosende, Sofia Rica
Paller, Angel Inciso
Limpin, Carellene Faith
Sauro, Sophia Arteche
Cordova, Marvin
Buenafe, Brigil Jame
Mesias, Mekka
Orosco, Krystelle Ann