Assessment

Chapter 11

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Assessment

Assessment is the first step in the nursing process and includes systematic collection, verification, organization, interpretation, and documentation of data for use by health care professionals.

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Purpose of Assessment

To determine the client’s functional abilities and the absence or presence of dysfunction.

Identification of the client’s skills, abilities, and behaviors available to promote treatment and recovery.

Establish a therapeutic relationship.

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Types of Assessment

Comprehensive Assessment Focused Assessment Ongoing Assessment Emergency Assessment

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Comprehensive Assessment

Usually completed upon admission. Provides baseline data:

• Physical and psychosocial aspects• Client’s perception of health• Presence of health risk factors• Client’s coping patterns

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Focused Assessment

Limited in scope in order to focus on a particular need or health problem.

Less detailed. Health care agencies in which short stays

are anticipated.

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Ongoing Assessment

Systematic monitoring and observation related to specific problems.

Database is broadened or confirmed. Determine client’s response to nursing

interventions. Identify any emerging problems.

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Ongoing Assessment

Home care nurses using ongoing assessments must direct the client to provide information relevant to the current problem.

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Emergency Assessment

A rapid assessment of clients experiencing life-threatening problems or crises.

Problems can be of physiological and/or psychological and sociological nature.

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Data Collection

Uses cognitive, interpersonal, and technical skills to elicit appropriate information.

A variety of sources and methods are used in compiling a comprehensive database.

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Types of Data

Subjective• Client’s perception, feelings, opinions,

concerns• Also referred to as symptoms• Cannot be readily observed by others

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Types of Data

Objective• Observable, measurable (quantitative)• Also referred to as signs• Standard assessment techniques• Laboratory and diagnostic testing

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Sources of Data

Client, family, significant others Medical records Other health care professionals Diagnostic tests Rounds Literature sources Nursing knowledge

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Methods of Data Collection

Observation• General appearance and behavior of the

client• Nonverbal cues may indicate pain, anxiety,

anger or physical changes.

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Methods of Data Collection

Interview• Collection of information about the client’s

health history and current status in order to determine client’s health needs.

• Effective interviewing depends on the nurse’s knowledge and ability to skillfully elicit information from the client.

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Interview

Preparation for the Interview• Review of the client’s medical records• Communication with other health team

members• Research of the presenting medical

diagnosis

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Interview Preparation

Assure adequate lighting. Maintain comfortable room temperature. Control for noise and distractions. Maintain client privacy. Establish time guidelines for interview. Promote client comfort.

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Interview Stages

Introduction Working Closure

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Interview Stages

Introduction Stage• Beginning of a nurse-client relationship.• Introductions are made.• Establishes rapport.• Defines roles.• Explains purpose and use of data.

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Interview Stages

Working Stage• Focuses on data collection.• Questions move from general to specific.• Closed-ended questions yield brief answers.• Open-ended questions encourage the client

to elaborate about a particular concern.

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Interview Stages

Closure Stage• Nurse summarizes data.• Asks for validation.

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Health History

Demographic Information Reason for Seeking Health Care Perception of Health Status Previous Illnesses, Hospitalizations,

Surgeries Client/Family Medical History

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Health History

Immunizations/Exposure to Communicable Disease

Allergies Current Medications Developmental Level

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Health History

Psychosocial History Value and Belief System Activities of Daily Living Review of Systems

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Physical Examination

Baseline Data Assessment Techniques

• Inspection• Palpation• Percussion• Auscultation

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Physical Examination

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Laboratory and Diagnostic Data

Objective data that serve as defining characteristics for various altered health states.

Effectiveness of interventions and progress toward health restoration are often monitored through test data.

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Data Verification

The process by which data are validated as complete and accurate.

Data are reviewed for inconsistencies or omissions.

Subjective and objective data are examined for congruence.

Findings should be compared with norms.

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Data Organization

Data clustering is organization of the information in order to identify strengths and weaknesses.

How data is clustered depends on the assessment model used.

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Data Organization

Assessment Models• Nursing Models• Non-Nursing Models

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Assessment Models

Nursing Models • Gordon’s Functional Health Patterns• Human Response Pattern• Theory of Self-care• Roy Adaptation Model• Leininger Sunrise Model

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Assessment Models

Non-Nursing Assessment Models• Body Systems Model• Hierarchy of Needs

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Data Interpretation and Documentation

Data clustering facilitates recognition of patterns and determination of further data that is needed.

Data interpretation is necessary for identification of nursing diagnoses.

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Data Interpretation and Documentation

Types of Assessment Formats• Open-Ended Formats• Checklist Formats• Combination Formats• Specialty Formats

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Sample Assessment Forms

Click one of the links below to view a sample assessment form• Application: assessment in the industrial clini

c• Sample assessment form: open-ended• Sample assessment form: combination

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Specialty Formats

The MDS Medicare Prospective Payment Assessment Form (MPAF)• Developed by the Health Care Financing

Administration (currently CMS).• Used in all skilled and long-term care

facilities that are funded by CMS.