Assessment

Assessment is important for every situation.

ROLES OF NURSES IN HEALTH ASSESSMENT

 The client interview
 Patient history and interview
 Cephalocaudal Assessment – head to toe assessment
 Assessment tools
 Documentation of data
 Analysis of data
TYPES OF ASSESSMENT
ASSESSMENT
 INITIAL COMPREHENSIVE ASSESSMENT – collection of
 Most CRITICAL PHASE of the Nursing Process
subjective data about the client’s perception of health of
 Ongoing and continuous all throughout the Nursing
all body parts or systems.
Process
 ONGOING OR PARTIAL ASSESSMENT – data collection
that occurs after the comprehensive database is
NURSING PROCESS
established.
 ASSESSMENT – collecting subjective data and objective
 FOCUSED/PROBLEM-ORIENTED ASSESSMENT –
data
thorough assessment of a particular client problem,
SUBJECTIVE DATA – It is done through interview on
which does not cover areas not related to the problem
the patient
 EMERGENCY ASSESSMENT – very rapid assessment
OBJECTIVE DATA – It is visible, physical examination.
performed in life-threatening situations.
 DIAGNOSIS – analyzing subjective and objective data to
make a professional nursing judgment
- Confirmatory process from the assessment
 PLANNING – determining outcome criteria and
developing a plan
- To make step to resolve diagnosis
 IMPLEMENTATION – carrying out the plan
- Application of the plan
 EVALUATION – assessing whether outcome criteria have
been met and revising the plan as necessary

HOW DOES NURSING ASSESSMENT DIFFER FROM MEDICAL

ASSESSMENT?

 PHYSICAL MEDICAL ASSESSMENT – focuses primarily on

the client’s physiologic development status
 NURSING ASSESSMENT – collects holistic subjective and
objective data to determine a client’s overall level of
functioning in order to make a professional clinical
judgment.

STEPS IN HEALTH ASSESSMENT

 Collection of subjective data
 Collection of objective data
 Validation of data
 Documentation of data
 Analysis of data
LEARNING OBJECTIVES  When did the pain start?
 DESCRIBE effective verbal and no-verbal communication  Did you take your medications this morning?
techniques to collect subjective client data  Laundry List
 EXPLAIN how a nurse would use COLDSPA to analyze a  is the pain severe, dull, sharp, mild, cutting or
client symptom piercing?
 EXPLAIN how to prepare oneself, the physical  Does the pain occur once every year, day, month
environment and the client for a physical examination or hour?
 DEMONSTRATE the four physical assessment techniques  Rephrasing
 DESCRIBE the significance of validation and  Client says “I can’t focus. My mind keeps
documentation of client data wandering.”
 The student nurse says, “You’re having difficulty
STEPS OF HEALTH ASSESSMENT concentrating Maam?”
 Well-placed phrases
1. COLLECTION OF SUBJECTIVE DATA  “uh-huh”, “yes” or “I agree”
INTERVIEW PROCESS  Inferring
 Pre-Introductory  Elicit more data and what you observe
 Introductory  Providing information
 Working  “Hello Maam, I am done doing your assessment and
 Summary and Closing as for my observation there is a noticeable mole at
your back as large as a pencil eraser with uneven
INTRODUCTION borders and with these findings, I’ll inform the
 INTRODUCE yourself physician so he may further assess the mole. I will
 State the PURPOSE get back to you in a while and if there is anything
 Make sure all information must remain CONFIDENTIAL you need Maam, I’ll just be in the situation. thank
(DPA-DATA PROTECT ACT) you for your cooperation, Maam.
 Make sure client is comfortable and has PRIVACY
 Build RAPPORT with the client using verbal and non- VERBAL COMMUNICATION TO AVOID
verbal skills  Biased or leading questions
 And you don’t have asthma or anything?
WORKING Do you have asthma or any other conditions?
 Complete Health History  How much pain are you in?
 Listening, observing cues and using critical thinking Are you in pain?
skills to interpret and validate information received from  There’s no history of cancer in your family, is there?
the client Is there any history of cancer in your family?
 Collaborating with the client to identify the client’s  You’re stressed about the surgery tomorrow, aren’t
problems and goals you?
How are you feeling about tomorrow’s surgery?
SUMMARY AND CLOSING  Rushing through the interview
 Validating problems and goals with the client  Reading the questions
 Identifying and discussing possible plans to resolve the
problem with the client NON-VERBAL Communication
 Making sure to ask if anything else concerns the client  Appearance
and if there are any further questions.  Facial expression
 Listening
ESTABLISHING RAPPORT  Attitude
 Verbal Communication  Demeanor
 Non-verbal Communication  Silence
 Posture
VERBAL COMMUNICATION
 Open-ended questions = “How” or “What”
 how are you feeling today, Maam?
 What allergies do you have?

 Closed-ended questions = “When” or “Did” FACTORS THAT AFFECT THE INTERVIEW

 TIME – the best time to conduct an interview is when the CHARACTER – Describe the sign or symptom. How does it
patient is physically comfortable and is free from pain. feel, look, sound, smell and so
 PLACE – a well-lighted, well-ventilated room that is forth?
relatively free from noise, movements and interruptions ONSET – when did it begin?
encourage communication. LOCATION – where is it? Does it radiate?
 DISTANCE – the distance between the nurse and the DURATION – How long does it last? Does it recur?
patient should be neither too small not too great, SEVERITY – how bad is it?
because people may feel uncomfortable when talking to PATTERN – what makes it better? What makes it worse?
someone who is too close or too far away. ASSOCIATED FACTORS – what other symptoms occur with it?
 LANGUAGE – failure to communicate in language, the
client can understand is a form of discrimination SAMPLE SCENARIO
A 50-year-old male client visited the health clinic with a chief
COMPLETE HEALTH HISTORY complaint of ABDOMINAL PAIN. As a nurse, how would you
 Biographical Data elicit information with regards to his reason for seeking
 Reasons for seeking health care health care using COLDSPA?
 History of present health care
 Past health history CHARACTER:
 Family health history  What does the pain feel like?
 Review of systems for current health problems  Is the pain dull, sharp, stabbing, cutting or piercing?
 Lifestyle and health practices profile ONSET:
 Developmental level  When did this pain start?
LOCATION:
BIOGRAPHICAL DATA  Where does it hurt the most?
 Name  Does it radiate or go to any part of the body?
 Address DURATION:
 Phone  How long does the pain last?
 Sex  Does it come and go or is it constant?
 Provider of history (patient or other) SEVERITY:
 Birth date  How intense is the pain? Rate it from 1 to 10.
 Place of birth PATTERN:
 Race or ethnicity background  What makes your abdominal pain worse or better?
 Primary and secondary languages (spoken and read)  Are there any treatments you’ve tries that relieve the
 Marital status pain?
ASSOCIATED FACTORS:
 Religious or spiritual practices
 Do you have any other problems that seem related
 Educational level
to your abdominal pain?
 Occupation
 How does it affect your life and daily activities?
 Significant others or support persons (availability)

PAST HEALTH HISTORY

REASONS FOR SEEKING HEALTH CARE
 Childhood illness
“What is your major health problem or concern at this time?”
CC = chief complaint  Immunizations to date
“How do you feel about having to seek health care?”  Adult illnesses
 Include any recent illnesses (i.e., infection)
 Surgeries
 hospitalizations
 accidents/injuries
 screening tests or exams
 allergies (seasonal, environmental, contact and food
allergies)
 medications (dosage, frequency and reason for taking)
- CURRENT MEDICATION: please include over-the-counter
Non-Prescription Medications such as vitamins and herbal
dietary supplements
HISTORY OF PRESENT HEALTH ASSESSMENT
FAMILY HEALTH HISTORY
COLDSPA
  DESCRIPTION OF TYPICAL DAY
What is your usual pattern within the day?
 OCCUPATION
What is your current occupation? How is your work
environment like?
 NUTRITION AND WEIGHT MANAGEMENT
What is your typical diet pattern? Who purchases and
prepare the meals?
 ACTIVITY LEVEL AND EXERCISE
Do you exercise? How many days in a week? For how many
minutes?
 SLEEP AND REST
What is your typical sleep pattern? How many hours do you
sleep?
 ALCOHOL, TOBACCO AND RECREATIONAL DRUG USE
REVIEW OF SYSTEMS (ROS) Do you drink alcohol? Or use tobacco? Do you smoke? Use
 Integumentary any recreational drugs?
 Head and Neck
 EENT 2. COLLECTION OF OBJECTIVE DATA
 Cardiac and Peripheral PHYSICAL ASSESSMENT
 Respiratory  EQUIPMENT needed
 GI  Preparation of SETTING, ONESELF and the CLIENT
 Breast  FOUR ASSESSMENT TECHNIQUES
 Musculoskeletal
 Neurologic EQUIPMENT
 Genitalia VITAL SIGNS
 Digital thermometer
 Analog watch
 Stethoscope
 Sphygmomanometer

SOME EQUIPMENT FOR ASSESSMENT

 Penlight
 Tape measure
 Tongue depressor
 Gauze
 Ruler
 Reflex hammer
 Magnifying glass

PREPARING FOR THE EXAMINATION

PREPARING THE PHYSICAL SETTING

ALL OF ROS is SUBJECTIVE; PA (PHYSICAL ASSESSMENT) is
 Comfortable, warm room temperature
OBJECTIVE.
 Private area free of interruptions
 Adequate lightning
 Firm examination table or bed
 Bedside table/tray

LIFESTYLE AND HEALTH PRACTICES PROFILE PREPARING ONESELF

 Practice, practice, practice
 Standard precaution – handwashing  Room should have a COMFORTABLE temperature and
- Before touching a patient lightning
- Before clean/antiseptic procedure  LOOK and OBSERVE before touching
- After body fluid exposure risk  Expose ONLY the BODY PART you are INSPECTING
- After touching a patient  Note for color, pattern, size, location, consistency,
- After touching patient surroundings symmetry, odor or sounds
 Should wear PPE PALPATION
 Use the sense of TOUCH
POSITIONING THE CLIENT  Palpation is used to determine:
 Standing - Texture (of hair and skin)
 Sitting - Temperature (of a skin area)
 Supine - Vibration (of the joints, fistula)
 Prone - Position, size, consistency and mobility (of organ and
 Sims’ position masses)
- Distention (of the bladder and abdomen)
- Pulsation (peripheral pulses)
- Tenderness or pain (upon pressure)
2 TYPES OF PALPATION
 Dorsal recumbent
1. LIGHT PALPATION
- The skin is lightly depressed
- The nurse extends the dominant hand’s fingers
parallel to the skin surface gently while moving hand
 Knee-chest in a circle
- It is necessary to determine the details of a mass,
the nurse presses lightly several times rather than
holding the pressure area
 Lithotomy - It is useful in assessing all parts of the body
2. DEEP PALPATION
- Use this method with extreme precaution because
pressure can damage internal organs and masses. It
is usually not indicated in clients who have acute
abdominal pain that is not yet diagnosed.
- It is useful in carefully assessing the internal organs
APPROACHING AND PREPARING THE CLIENT of the abdomen
 Establish RAPPORT - Use gloves prn (especially for patients with
 State the PURPOSE and the possible change of position communicable diseases that can acquired from skin
frequently during examination contact)
 Respect client’s desires and requests PERCUSSION
 Client’s GOWN and PRIVACY - Tapping the body parts to produce sound waves
 Begin examination with the least intrusive procedures o Elicit pain
o Determine location, size and shape
PHYSICAL EXAMINATION TECHNIQUE o Determining density
INSPECTION o Detecting abnormal masses
PALPATION o Eliciting reflex
PERCUSSION AUSCULATATION
AUSCULTATION - The stethoscope should have both the diaphragm
and the bell
- The diaphragm best transmits high-pitched sound,
such as from the lungs, and the bell is best for low-
pitched such as the fetal heart sound.

INSPECTION
 Use of SENSES
 Example: client has cc of chest pain
 Client reports a short stabbing pain in the chest. It
started a few days ago while working at the
construction site. It radiates from neck to his left arm
and lasts for about 30 seconds. Rated pain as 6 on a
scale of 1 to 10. Pain was relieved through rest and
felt tired and weak after the episode.

It is important to remember to document only what the client

tells you and what you observe – NOT what you interpret or
infer from the data
CLEAR AND CONCISE DOCUMENTATION

STEPS OF HEALTH ASSESSMENT

1. COLLECTION OF SUBJECTIVE DATA
 INTERVIEW PROCESS
 NURSING HEALTH HISTORY
IPPA – all systems except abdomen o Biographic Data, Reason for Seeking
IAPP – abdominal part Health Care, Present Health History,
Past Health History, Family History,
3. VALIDATING DATA ROS, Lifestyle and Health Practices
 The act of “double-checking”, verifying data if it is 2. COLLECTION OF OBJECTIVE DATA
accurate and factual
 Physical Assessment
 REPEAT assessment
o Start with least intrusive assessment
 CLARIFY data with the client by asking additional
 Cephalocaudal Assessment
information
 Abdominal Assessment
 VERIFY data with other health care professional
3. VALIDATION OF DATA
 COMPARE objective and subjective data to uncover
 Repeat, Clarify, Verify and Compare
discrepancies
4. DOCUMENTATION OF DATA
 CLEAR and CONCISE documentation
4. DOCUMENTING DATA
 To promote EFFECTIVE COMMUNICATION among
Thinking critically is to analyze data and make informed
the multidisciplinary health team members
nursing judgments
- Adoption and use of Health Information Technology
(HIT)
- EHR (Electronic Health Record) and EMR (Electronic
Medical Records)
- EHR’s will improve the quality, safety and efficiency
of client care

KEEP ALL DOCUMENTED INFORMATION CONFIDENTIAL

 Document legibly or print neatly in nonerasable ink
 Use only acceptable and approved abbreviations
 If an error occurs in documentation, draw a line on the
wrong data and write mistaken entry with your initials or
signature
 Avoid wordiness that creates redundancy
CRITICAL THINKING
 Record the findings, NOT how they were obtained
 Critical thinking is the way in which the nurse
 DO NOT write “NORMAL” for normal findings
PROCESS information using knowledge, past
 Don’t make premature judgments
experiences, intuition and cognitive abilities to
 Record COMPLETE information formulate conclusions or diagnoses.
- Use COLDSPA  Characteristic a nurse must develop to be able to
THINK CRITICALLY