4. OBJECIVES :
• Discuss the role of Nurses in Health
Assessment Process
• List and explain the types, methods
techniques, components of Assessment
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5. • Health assessment is an essential nursing
function which provides foundation for quality
nursing care and intervention
• It helps to identify the strengths of the clients
in promoting health
• Health assessment helps to identify client’s
needs, clinical problems
• To Evaluate responses of the person to health
problems and intervention
Health Assessment
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7. ASSESSMENT
Is the first step to determine heath
status. It is gathering of information
to have all the “necessary puzzle pieces” to make a
clear picture of the person’s health status
Definition : Assessment is the deliberate and
systematic collection of data to determine clients
current and past health status, functional status and
to determine client’s present and coping pattern
( Carpenito)
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8. • Assessment is a part of each activity
the nurse does for and
with the patient
(Atkinson & Muray – 1991
Nursing assessment focus upon the
client’s response to a health problem
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9. “ Nursing assessment should include client’s
perceived needs, health problems related
experience, health practices values and life styles”
( Bandman and Bandman (1995)
• To be most useful- the data collected should be
relevant to a particular health problem
• Therefore – nurses should think critically
about what to assess 9
12. Assessment identifies the pt’s strengths
and limitations
• It is a done continuously through out
the nursing Process
• Initial assessment baseline data
identify nsg diagnoses develop plan
Implement plan assess pt response
Finally you assess the effectiveness of
your plan for the care of your pt
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13. • What you do?
• Where do you begin ?
You begin with Assessment
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14. Types of patients & Assessment
• Pediatric – neonate ,infant, children of all categories)
• Adolescent
• Young adults & adults
• Geriatric/elderly
Conscious
Unconscious
Delirious
• Psychiatric – Different categories
• Hysteric
ACUTE --- CHRONIC patients
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15. Purposes of Assessment
1. To collect data pertinent to the patient’s
health status – subjective /objective
2. To identify deviations from normal
3. To discover the patients
strengths,limitations and coping resources
4. To pinpoint actual problems
5. To spot factors that place the pt at risk of
health problems
6. To build rapport with patient and family 15
17. Initial Assessment
It is done within specified time after admission
to Hospital
Purpose: To establish a complete data base for
problem identification, reference and future
comparison Eg: Admission assessment
Focus or Ongoing Assessment
Purpose: To determine the status of a specific
problem identified in the earlier assessment
& to identify new or overlooked problem
Eg: Hrly fluid intake output assessment 17
18. Emergency Assessment
During any physiologic and psychologic crisis
of the patient
Purpose: To identify life threatening problems
eg. ●ABC assessment in Cardiac arrest
●Assessment of suicidal attempt on violence
Time lapsed Assessment
Several months after the initial assessment
Purpose: To compare current status to baseline
data previously obtained
Eg Reassessment of clients functional health
patterns in home care 18
21. “The most practical lesson that can
be given to a nurse to teach them
what to observe “
Florence Nightingale ( 1859)
“For it may be said, not that the habit of
ready and correct observation will by itself
make us useful nurses. But that without it
we shall be useless with all our devotion “
(Nursing- what it is and what it not : F. Nightingale Page
160. (1860)
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22. Observing
Is a conscious deliberate skill developed
only through and with an organized
approach.
Eg. Data observed with 4 senses – vision,
hearing, smell and touch
Interviewing
Is a planned communication or a conversation with
a purpose Eg. History taking
2 approaches : Directive , non directive
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24. EXAMINING
Physical Examination
• Systematic data collection method –
Observational skills to detect health problems
Assessment sequencing
• Head – to- Toe assessment
• Body system assessment (Signs and symptoms
– complaints – lead to clues )
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25. The Art of Physical Examination …
Using Techniques of –
• Inspection
• Palpation
• Percussion
• Auscultation
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26. INSPECTION : close and careful visualization of
the person and of each body system
Eg Rashes…. Color changes … edema
PALPATION
• Temp •Texture
• Moisture •organ size & location
• Rigidity & spasticity •Crepitation /vibration
• Position& size •Tenderness/pain
•Presence of lumps & masses
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27. PERCUSSION :
Assess underlying structures of
location,
size, density of underlying tissues
AUSCULTATION :
Listening to sounds produced
by the body
• Stethoscope --
• Doppler
• Feto- scope
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28. 4 Closely Related Activities
ASSESSMENT
Process
Collecting Data
Validating Data
Documenting
Data
Organizing Data
REPORT
DATA
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29. 1. Collecting Data : Gathering Information
Sources of data
Primary or Secondary
PRIMARY SOURCE ----- patient –
Alert, oriented patient is most reliable source
Aged, mentally deterioration seriously ill ???
SECONDARY SOURCE – Family members ,
significant others, medical records,
diagnostic procedures
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30. 1. COLLECTING DATA
Process of gathering information
Nurse collects …..
A. Subjective –(Symptom)
Verbal statement by the patient
Eg… Nausea , pain , fatigue ,itching
B. Objective--- (Signs) (overt ) data
-Detected by an observer - can be measured over
an accepted standard
Can be seen, felt, heard, smelt – information by
observation or examination
Eg. Discoloration of the skin
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31. PQRST Method for PAIN Assessment
• O = Onset What you were doing when the pain
started ?
Was the onset sudden or gradual ?
• P = Provokes - What causes pain?
What makes it better? What makes it Worse?
• Q = Quality What does it feel like?
Is it sharp? Dull?
Stabbing? Burning? Crushing?
( Try to let patient describe the pain)
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32. • R = Radiates Where does the pain radiate?
–Is it in one place?
–Does it go anywhere else?
• Did it start elsewhere and now localized to one
spot?
• S = Severity
How severe is the pain on a scale of 1 - 10
(This is a difficult one as the rating will differ from
patient to patient )
• T = Time
–Time pain started?
–How long did it last?
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33. While Collecting data …..
When you communicate to collect data
Aware of verbal /nonverbal messages to patient
• Genuineness : be open ,honest and sincere
with patient
• Respect : be Non judgemental, let him feel
accepted as a unique individual
• Empathy: Is knowing what patient means and
acknowledge and understanding how he /she
feels
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34. ORGANIZING DATA
• Cluster the data into groups of information
( identify the pattern of illness) (Data base)
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35. VALIDATING DATA
• Double checking or verifying the data whether
it is factual or accurate
• The assessment information must be accurate,
factual and complete –
• Nursing diagnosis and interventions based on
this
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36. DOCUMENTING DATA
• Accurate documentation is essential which include
all data collected about client’s health status.
Record in a FACTUAL manner NOT interpretation
• Eg. Recording the breakfast intake as –
Ate 2 pieces of Bread toast , 1 egg and
a cup of coffee
Instead of “Good appetite”
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37. REPORTING - When you will Report?
• Depending on each Patient---
• Disease conditions – potential problems
• Family interests
• Psychological upset – may lead to suicidal
attempt
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38. Skills require for Health Assessment
A. Cognitive skills : Assessment is a “thinking “process
• Critical thinking --- why , how .. What
• Clinical decision making use knowledge & experience
B. Problem solving Skill – with
Scientific methods- experience –
“ intuition” (with experience)
C. Psychomotor skills – Assessment is “doing”
D. Affective/Interpersonal Skill –
Assessment is “feeling” trust and mutual respect
E.Ethical skills : Assessment is “ being responsible &
accountable” for your practice
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39. Medical Assessment Vs
Nursing Assessment
Assessment is the part of medical practice
the process is same BUT
The outcome differ
• Medical assessment Diagnosis and treatment
• Nursing assessment - focus on patient as a person
and reach to the optimal level of wellness
(Holistic Approach)
• Both should compliment—not CONTRADICT
• Nursing assessment contribute to identification of
medical problems
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