NR224 FUNDAMENTALS CH 16 NURSING ASSESSMENT
Assessment
The deliberate & systematic collection of info about a pt to determine the pt's current &
past health & functional status & their present & past coping patterns
Nursing assessment includes two steps:
1. Collection of info from a primary source (a patient) and secondary sources (e.g.,
family or friends, health professionals, & the medical record)
2. The interpretation & validation of data to ensure a complete database
Describe the relationship b/t critical thinking & nursing assessment.
Critical thinking is a vital part of assessment. While gathering data about a p, you
synthesize relevant knowledge, recall prior clinical experiences, apply critical thinking
standards & attitudes, & use professional standards of practice to direct your
assessment in a meaningful & purposeful way. Your knowledge from the physical,
biological, & social sciences allows you to ask relevant questions & collect relevant
history & physical assessment data related to a pt's presenting health care needs.
Types of Assessments
The pt-centered interview during a nursing health history.
A physical examination.
The periodic assessments you make during rounding or administering care.
Cue
Info that you obtain through use of the senses.
Inference
Your judgment or interpretation of cues.
Comprehensive assessment
Moves from the general to the specific.
Typically certain aspects of a situation stand out as most important.
You then ask more focused questions on the basis of the patient's responses & physical
signs.
Problem oriented:
Focus on a pt's presenting situation & begin w/ problematic areas.
Ask the pt follow-up questions to clarify & expand assessment so you can understand
the full nature of the problem.
Subjective data
Pt's verbal descriptions of their health problems.
Often reflect physiological changes, which you further explore through objective review
of body systems.
Objective data
Observations or measurements of a pt's health status.
Objective data is measured on the basis of an accepted standard such as the F or C
measure on a thermometer, in or cm on a measuring tape, or a rating scale (0-10 pain).
When objective data is collected, apply critical thinking intellectual standards (clear,
precise, & consistent) so findings can be interpreted correctly.
, Sources of data
1. Patient (interview, observation, physical examination)
2. Family & significant others (obtain pt's agreement first)
3. Health care team
4. Medical records
5. Scientific literature & other records
6. Nurses experience
Patient (interview, observation, physical examination)
- A pt is usually your best source of info. Pts who are conscious, alert, & able to answer
questions w/o cognitive impairment provide the most accurate info. An older adult may
require more time for assessment than someone younger if hearing or cognitive deficits
exist. Use short (not leading) questions, keep your language uncomplicated, & listen to
the pt's perspective carefully.
Family & significant others (obtain pt's agreement first)
- Primary sources of info for infants or children, critically ill adults, & pts who are
mentally handicapped or have cognitive impairment. In cases of severe illness or
emergency situations, families are often the only sources of info for health care
providers. The family & significant others are also important secondary sources of info.
Not only do they supply info about the pt's current health status, but they are also able
to tell when changes in the pt's status occurred.
Health care team
- You frequently communicate w/other health care team members to assess pts. In the
acute care setting, the change-of-shift report, bedside rounds, & pt hand-off are ways
that nurses from one shift communicate info to nurses on the next shift. Every member
of the team is a source of info for Identifying & verifying essential info about the pt.
Medical records
- The medical record is a source for the pt's medical history, lab & diag test results,
current physical findings, & the primary health care provider's treatment plan. The
record is a valuable tool for checking the consistency & similarities of data with your
personal observations.
Scientific literature & other records
- Reviewing recent nursing, medical, & pharmacological literature about a pt's illness
completes a pt's assessment database. This review increases knowledge about a pt's
diagnosed problems, expected symptoms, treatment, prognosis, & established
standards of therapeutic practice.
- Educational, military, & employment records often contain significant health care
information (immunizations). If a pt received services at a community clinic/different
hospital, you need written permission from the pt/guardian to access the record.
Nurses experience
-Your experiences in caring for pts are a source of data. Through clinical experience
you observe other pts' behaviors & physical s/s; track trends & recognize clinical
changes; & learn the types of questions to ask, choosing the questions that will give the
most useful info.
Patient-centered interview
Is relationship based & is an organized conversation focused on learning about the well
& the sick as they seek care.
Assessment
The deliberate & systematic collection of info about a pt to determine the pt's current &
past health & functional status & their present & past coping patterns
Nursing assessment includes two steps:
1. Collection of info from a primary source (a patient) and secondary sources (e.g.,
family or friends, health professionals, & the medical record)
2. The interpretation & validation of data to ensure a complete database
Describe the relationship b/t critical thinking & nursing assessment.
Critical thinking is a vital part of assessment. While gathering data about a p, you
synthesize relevant knowledge, recall prior clinical experiences, apply critical thinking
standards & attitudes, & use professional standards of practice to direct your
assessment in a meaningful & purposeful way. Your knowledge from the physical,
biological, & social sciences allows you to ask relevant questions & collect relevant
history & physical assessment data related to a pt's presenting health care needs.
Types of Assessments
The pt-centered interview during a nursing health history.
A physical examination.
The periodic assessments you make during rounding or administering care.
Cue
Info that you obtain through use of the senses.
Inference
Your judgment or interpretation of cues.
Comprehensive assessment
Moves from the general to the specific.
Typically certain aspects of a situation stand out as most important.
You then ask more focused questions on the basis of the patient's responses & physical
signs.
Problem oriented:
Focus on a pt's presenting situation & begin w/ problematic areas.
Ask the pt follow-up questions to clarify & expand assessment so you can understand
the full nature of the problem.
Subjective data
Pt's verbal descriptions of their health problems.
Often reflect physiological changes, which you further explore through objective review
of body systems.
Objective data
Observations or measurements of a pt's health status.
Objective data is measured on the basis of an accepted standard such as the F or C
measure on a thermometer, in or cm on a measuring tape, or a rating scale (0-10 pain).
When objective data is collected, apply critical thinking intellectual standards (clear,
precise, & consistent) so findings can be interpreted correctly.
, Sources of data
1. Patient (interview, observation, physical examination)
2. Family & significant others (obtain pt's agreement first)
3. Health care team
4. Medical records
5. Scientific literature & other records
6. Nurses experience
Patient (interview, observation, physical examination)
- A pt is usually your best source of info. Pts who are conscious, alert, & able to answer
questions w/o cognitive impairment provide the most accurate info. An older adult may
require more time for assessment than someone younger if hearing or cognitive deficits
exist. Use short (not leading) questions, keep your language uncomplicated, & listen to
the pt's perspective carefully.
Family & significant others (obtain pt's agreement first)
- Primary sources of info for infants or children, critically ill adults, & pts who are
mentally handicapped or have cognitive impairment. In cases of severe illness or
emergency situations, families are often the only sources of info for health care
providers. The family & significant others are also important secondary sources of info.
Not only do they supply info about the pt's current health status, but they are also able
to tell when changes in the pt's status occurred.
Health care team
- You frequently communicate w/other health care team members to assess pts. In the
acute care setting, the change-of-shift report, bedside rounds, & pt hand-off are ways
that nurses from one shift communicate info to nurses on the next shift. Every member
of the team is a source of info for Identifying & verifying essential info about the pt.
Medical records
- The medical record is a source for the pt's medical history, lab & diag test results,
current physical findings, & the primary health care provider's treatment plan. The
record is a valuable tool for checking the consistency & similarities of data with your
personal observations.
Scientific literature & other records
- Reviewing recent nursing, medical, & pharmacological literature about a pt's illness
completes a pt's assessment database. This review increases knowledge about a pt's
diagnosed problems, expected symptoms, treatment, prognosis, & established
standards of therapeutic practice.
- Educational, military, & employment records often contain significant health care
information (immunizations). If a pt received services at a community clinic/different
hospital, you need written permission from the pt/guardian to access the record.
Nurses experience
-Your experiences in caring for pts are a source of data. Through clinical experience
you observe other pts' behaviors & physical s/s; track trends & recognize clinical
changes; & learn the types of questions to ask, choosing the questions that will give the
most useful info.
Patient-centered interview
Is relationship based & is an organized conversation focused on learning about the well
& the sick as they seek care.
