Nursing Assessment

Mr.G.Harsha
Nursing officer-AIIMS Mangalagiri
 We are going to Discuss

 What is Nursing Assessment

 Purpose of nursing assessment
 Types of assessment
 Steps of assessment
 Data collection & methods.
 Physical assessment
 Physical assessment techniques
 Organising the data
 Data validation.
 Documentation of the Data.
 Introduction

• Nursing is an art of applying scientific

principles in a humanitarian way to
care of people
• The nursing process serves as the
organizational framework for the
practice of nursing.
 Assessment Definition
Is the systematic and continuous:
• collection
• organization
• validation
• documentation of data.
 The Process

Assessment

Organize Documenting
Collect data Validate data
data data
 The Process

• The nurse gathers information to identify the health

status of the patient.

• Assessments are made initially and continuously

throughout patient care.
 Purposes of assessment

To establish Database: all the information about a

client: it includes:
• The nursing health history
• Physical examination
• The physician's history
• Results of laboratory and diagnostic tests
 PURPOSE OF ASSESSMENT

The purposes is
1.To validate a diagnosis
2.To provide basis for effective nursing care.
3.It helps in effective decision making
4.Basis for accurate diagnosis
5.It promote holistic nursing care
6.To provide effective and innovative nursing care
7.To collecting data for nursing research
8.To evaluation of nursing care
 Types of Assessment

• Types vary according to their purpose,timing,time gap, and

client status.

• Medical assessment focus on disease.

• Nursing assessment focus on clients response to health

problem.
 Types of Assessment

Assessment

Initial Focus Time-lapsed Emergency

Assessment Assessment Assessment
Assessment
 Initial comprehensive assessment

 Performed within specified time after admission.

 Recommended standard time with in 30 min.

 Initial assessment time will vary based on setting

 The purposes are to evaluate the client’s health status, to
identify functional health patterns that are problematic, and to
provide an in-depth, comprehensive database, which is critical
for evaluating changes in the client’s health status in subsequent
assessments. Ex: Nursing admission assessment
 Summary Nursing initial/
Admission Assessment

• Documentation: Name, CR number, age, date, time, probable medical

diagnosis, chief complaint, the source of information (two patient identifiers)

• Past medical history: Prior hospitalizations and major illnesses and

surgeries.

• Assess pain: Location, severity, with use of a pain scale.

• Allergies: Medications, foods, and environmental; nature of the reaction and

seriousness; intolerances to medications.

• Medications: Confirm all the list of medications that patient is taking,

names, and dosages of medications, frequency, including supplements and
over-the-counter medications.
 Continued……..

Valuables: Record and hand over all the personal belongings to

patient attendants & provide and label denture cups, Eye glass
.boxes

Rights: Orient patient, caregivers, and family to location, rights,

.and responsibilities; goal of admission and discharge goal

.Activities: Check daily activity limits and need for mobility aids

.Falls: Assess Fall Risk and initiate fall precautions

Psychosocial: Evaluate any signs of agitation, restlessness,
.hallucinations, depression, suicidal ideations, or substance abuse

Nutritional: Appetite, changes in body weight, need for nutritional

consultation based on body mass index (BMI) calculated from
.measured height and weight on admission

Vital signs: Temperature , heart rate, respiratory rate, blood

.pressure, pain level on admission, oxygen saturation
 Problem-focused assessment

A problem focus assessment collects data about a problem that

has already been identified. This type of assessment has a
narrower scope and a shorter time frame than the initial
assessment. In focus assessments, nurse determine whether the
problems still exists and whether the status of the problem has
changed (i.e. improved, worsened, or resolved). This assessment
also includes the appraisal of any new, overlooked, or
misdiagnosed problems. In intensive care units, may perform
focus assessment every few minute. Eg: Hourly checking of vital signs
of fever patient.
 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 rapid identification of and intervention for the client’s
health problems. Often the client’s difficulties involve airway,
breathing and circulatory problems (the ABCs). Abrupt changes in
self-concept (suicidal thoughts) or roles or relationships (social
conflict leading to violent acts) can also initiate an emergency.
Emergency assessment focuses on few essential health patterns and
is not comprehensive.
 Time-lapsed assessment
or Ongoing assessment
 Comparison of client’s current status to baseline obtained
previously, detection of changes in all functional health
patterns after an extended period of time has passed Several
months after initial assessment.
 To compare the client’s current health status with the data
previously obtained.
 Several months (3,6,9 months or more) between assessment.
 Steps Of Assessment

A. Collection of data
a) Subjective data collection
b) Objective data collection

B. Validation of data
C. Organization of data
D. Recording/documentation of data
 Collection of Data

• Gathering of information about the client

• Includes physical, psychological, emotion, socio-cultural, spiritual
factors that may affect client’s health status
 Includes past health history of client (allergies, past surgeries,
chronic diseases, use of folk healing methods)
 Includes current/present problems of client (pain, nausea, sleep
pattern, religious practices, medication or treatment the client is
taking now)
 Types of Data

When performing an assessment the nurse gathers

subjective and objective data.

Subjective data (symptoms or covert data):

Are the verbal statements provided by the Patient.
Statements about nausea and descriptions of pain and
fatigue are examples of subjective data.
 Objective Data

Objective data (signs or overt data), are detectable

by an observer or can be measured or tested
against an accepted standard. They can be seen,
heard, felt, or smelt, and they are obtained by
observation or physical examination. For
example: discoloration of the skin
 Data Collection Methods

1. Observing: to observe is to gather data by using the

senses.
2. Interviewing: an interview is a planned communication
or conversation with a purpose.
3. Examining: Performance of a physical examination. The
physical examination is often guided by data provided
by the patient. A head-to-toe approach is frequently used
to provide systematic approach that helps to avoid
omitting important data
Physical assessment
 Physical examination

• A structured physical examination allows the nurses to

obtain a complete assessment of the patient. Observation,
inspection, palpation, percussion and auscultation are
techniques used to gather information. Clinical judgment
should be used to decide on the extent of assessment
required.
 Assessment Sequencing

• Head – to - Toe Assessment

• Body Systems Assessment

 Head-to-toe Assessment
Physical Assessment using head toe approach

Test hearing General

Cranial nerves General health status
Inspect lymph nodes Vital signs and weight
Inspect neck veins Nutrional status
Chest Mobility and self care
Inspect and palpate breast Observe posture
Inspect and auscultate lungs Assess gait and balance
Auscultate heart Evaluate mobility
Abdomen Activities of daily living
Inspect, auscultate, palpate four Head face and neck
quadrants Evaluate cognition
Palpate and percuss liver, stomach, LOC
bladder Orientation
Bowel elimination Mood
Urinary elimination Language and memory
Sensory function
Test vision
Inspect and examine ears
Cont…..
Extremities
Palpate arterial pulses Skin, hair and nails
Observe capillary refill Inspect scalp, hair & nails
Evaluate edema Evaluate skin turgor
Assess joint mobility Observe skin lesion
Measure strength Assess wounds
Assess sensory function Genitalia
Assess circulation, movement, & Inspect female client
sensation Inspect male client
Deep tendon reflexes
Inspect skin and nails
 Body System approach
Review Of Systems

General presentation of symptoms: Fever, chills, malaise, pain, sleep

patterns, fatigability
Diet: Appetite, likes and dislikes, restrictions, written dairy of food intake
Skin, hair, and nails: rash or eruption, itching, color or texture change,
excessive sweating, abnormal nail or hair growth
Musculoskeletal: Joint stiffness, pain, restricted motion, swelling, redness,
heat, deformity
Head and neck:
Eyes: visual acuity, blurring, diplopia, photophobia, pain, recent change in
vision
Ears: Hearing loss, pain, discharge, tinnitus, vertigo
Nose: Sense of smell, frequency of colds, obstruction, epistaxis, sinus
pain, or postnasal discharge
Throat and mouth: Hoarseness or change in voice, frequent sore throat,
bleeding o swelling, of gums, recent tooth abscesses or extractions, soreness
of tongue or mucosa.
 Endocrine and genital reproductive: Thyroid enlargement or tenderness,
heat or cold intolerance, unexplained weight change, polyuria, polydipsia,
changes in distribution of facial hair; Males: Puberty onset, difficulty with
erections, testicular pain, libido, infertility; Females: Menses {onset,
regularity, duration and amount}, Dysmenorrhea, last menstrual period,
frequency of intercourse, age at menopause, pregnancies {number,
miscarriage, abortions} type of delivery, complications, use of
contraceptives; breasts {pain, tenderness, discharge, lumps}

 Chest and lungs: Pain related to respiration, dyspnea, cyanosis, wheezing,

cough, sputum {character, and quantity}, exposure to tuberculosis (TB), last
chest X-ray
 Heart and blood vessels: Chest pain or distress, precipitating causes,
timing and duration, relieving factors, dyspnea, orthopnea, edema,
hypertension, exercise tolerance
 Gastrointestinal: Appetite, digestion, food intolerance, dysphagia,
heartburn, nausea or vomiting, bowel regularity, change in stool
color, or contents, constipation or diarrhea, flatulence or
hemorrhoids
 Genitourinary: Dysuria, flank or suprapubic pain, urgency,
frequency, nocturia, hematuria, polyuria, hesitancy, loss in force of
stream, edema, sexually transmitted disease
 Neurological: Syncope, seizures, weakness or paralysis,
abnormalities of sensation or coordination, tremors, loss of memory
 Psychiatric: Depression, mood changes, difficulty concentrating
nervousness, tension, suicidal thoughts, irritability.
 Pediatrics: along with systemic approach in case of pediatrics,
measure anthropometric measurement and neuromuscular
assessment.
 Assessment techniques

• Inspection
• Palpation
• Percussion
• Auscultation
 Assessment techniques - Inspection

• Close and careful visualization of the person as a whole

and of each body system
• Ensure good lighting
• Perform at every encounter with your client
 Assessment techniques Palpation

• Temperature, Texture, Palpation Techniques

Moisture
• Organ size and location • Light --Depth of about 1 cm
• Rigidity or spasticity • Deep--Depth of about 4–5 cm
• Position & Size • Bimanual palpation
• Presence of lumps or
masses
• Tenderness, or pain
 Assessment techniques Percussion

• Assess underlying structures

for location, size, density of
underlying tissue.

• Direct

• Indirect
 Percussion Sounds

• Resonance: A hollow sound.

• Hyper resonance: A booming/Drums like
sound.
• Tympany: A musical sound or drum sound like
that produced by the stomach.
• Dullness: Thud sound produced by dense
structures such as the liver, and enlarged
spleen, or a full bladder.
• Flatness: An extremely dull sound like that
produced by very dense structures such as
muscle or bone.
 Assessment techniques
Auscultation

• Listening to sounds
produced by the body

• Instrument: stethoscope (to

skin)
• Diaphragm –high pitched
sounds
Heart
Lungs
Abdomen
• Bell – low pitched sounds
Blood vessels
 Assessment techniques -
Setting

• Environment &
Technique
Equipment
• General survey
• Head to toe or systems
approach
• Minimize exposure
• Areas to assess first –
unaffected areas, external
before internal parts
 Physical Health Exam-General Survey

• Appearance
• Age, skin color, facial features
• Body Structure - Stature, nutrition, posture, position, symmetry
• Mobility - Gait, ROM

• Behavior
• Facial expression, mood/affect, speech, dress, hygiene

• Cognition
• Level of Consciousness and Orientation (x4)

• Include any signs of distress- facial grimacing, breathing

problems
 Complete Health History

• Biographical data
• Reason for Seeking Care
• History of Present Illness
• Past Health
• Accidents and Injuries
• Hospitalizations and Operations
• Family History
• Review of Systems
• Functional Assessment ( Activities of Daily
Living)
• Perception of Health
 Sources of Data
Data can be obtained from primary or secondary sources.

The primary source of data is the patient. In most instances the

patient is considered to be the most accurate reporter. The alert and
oriented patient can provide information about past illness and
surgeries and present signs, symptoms, and lifestyle.
When the patient is unable to supply information because of
deterioration of mental status, age, or seriousness of illness,
secondary sources are used.
•The Secondary sources of data include family members,
significant others, medical records, diagnostic procedures.
•Members of the patient's support system may be able to
furnish information about the patient's past health status,
current illness, allergies, and current medications.
•Other health team professionals are also helpful secondary
sources (Physicians, other nurses.
 Organizing data

The nurse uses a written or computerized format that

organizes the assessment data systematically. The format
may be modified according to the client's physical status.
 Validating Data

The information gathered during the

assessment phase must be complete, factual,
and accurate because the nursing diagnosis and
interventions are based on this information.

Validation is the act of "double-checking" or

verifying data to confirm that it is accurate and
factual.
 Purposes of Data Validation

• Ensure Data must be complete, factual& accurate

• Ensure that objective and subjective data agree
• Obtain additional data that may have been overlooked
• avoid jumping to conclusion
• differentiate cues and inferences
• Cues:- Subjective/objective data that can be directly observed by
the nurse.(can see, hear, smell & measure).
• Inferences:- Nurses conclusion/interpretation of the cues.
• Ex:-A nurse observes the cues that an incision is red,hot &swollen.
Inference that incision is infected.
 Data Requiring Validation

Not every piece of data you collect must be verified. For example:
you would not need to verify or repeat the client’s pulse,
temperature, or blood pressure unless certain conditions exist.
Conditions that require data to be rechecked and validated include:

• Discrepancies or gaps between the subjective and objective data. For example,
a male client tells you that he is very happy despite learning that he has
terminal cancer.
 Data Requiring Validation

• Discrepancies or gaps between what the client says at one time and
then another time. For example, your female patient says she has
never had surgery, but later in the interview she mentions that her
appendix was removed at a military hospital when she was in the
navy
• Findings those are very abnormal and inconsistent with
other findings. For example, the client has a temperature
of 104oF degree. The client is resting comfortably. The
client’s skin is warm to touch and not flushed.
 Methods of validation

• Recheck your own data through a repeat assessment. For example, take the
client’s temperature again with a different thermometer.
• Clarify data with the client by asking additional questions. For example: if a
client is holding his abdomen the nurse may assume he is having abdominal
pain, when actually the client is very upset about his diagnosis and is
feeling
• Verify the data with another health care professional. For example, ask a more
experienced nurse to listen to the abnormal heart sounds you think you have just
heard.
• Compare you objective findings with your subjective findings to uncover
discrepancies. For example, if the client state that she “never gets any time in the
sun” yet has dark, wrinkled, suntanned skin, you need to validate the client’s
perception of never getting any time in the sun
 Documentation of the
assessment

The assessment is documented in the

patient's medical or nursing records, which
may be on paper or as part of the electronic
medical record which can be accessed by all
members of the healthcare team.
 Conclusion

Assessment is the first and most critical step of nursing

process. Accuracy of assessment data affects all other
phases of the nursing process. A complete data base of
both subjective and objective data allows the nurse to
formulate nursing diagnosis, develop client goals, and
intervenes to promote heath and prevent disease.