ASSESSMENT

 Deliberate and systematic collection of data about patient.

 Reveal a patient’s current and past health status,
 Functional status, and
 Present and past copping patterns
Two steps
• Collection and verification of data from a primary source and secondary source.
• Analysis of all data as a basis for the second step of the nursing process, developing nursing
diagnosis, and identifying collaborative problem.
You need…
 Critical thinking
 Attitudes
 Intellectual standards
 Expertly, clarify data, gather further data for validation
Data Collection
• Cue : information
• Inference: your judgment or interpretation of those cues

STEPS
• Observation -> assessment cues and pattern of information that suggest problem areas.
• Assessment model:
– From general to specific
– Problem-focused approach
Cluster cues -> make inference -> identify emerging patterns and potential problems
TYPES OF DATA
• Subjective Data: your patient’s verbal descriptions of their health problems.
Objective Data: observation or measurements of a patient’s health status.  clear, precise,
consistent.
SOURCE OF DATA
• Provides information about the patient’s:
– level of wellness,
– risk factors,
– health practices and goals,
– Patterns of health and illness
• Patient
• Family and significant other
• Health care team
• Medical records
• Other records and literature
Methods of Data Collection
 • Interview and Health history
• Physical Examination
• Observation of Patient’s behavior
• Diagnostic and Laboratory data
INITIAL INTERVIEW
• Introduce your self to the patient, explain your role, and explain the role of others during
care
• Establish a caring therapeutic relationship with the patient
• Gain insight about the patient’s concerns and worries
• Determine the patient’s goals and expectations of the health care delivery system
• Obtain cues about which parts of the data collection phase require in-depth investigation
Three phases of interview
Always prepare for an interview.
• Orientation
– Introducing yourself, your position.
– Explaining the purpose of the interview
– Establish trust and confidence
– Begin a relationship
• Working
– Gather information
– Focus, orderly, unhurried
• Termination
Termination
• Give your patient clue that the interview is coming to an end.
– Exmp: “there are just two more questions”
• Summarize the important points
• Ask your patient if your summary is accurate
• End the interview in a friendly manner
– Exmp: “Thanks Mrs.Tillman, you have given to me a good picture of your health and
how you have been affected”
Interview Technique
• Good interview environment: free of distractions, unnecessary noise, and interruption
• Use open-ended questions
– Tell me about the problems you are having
– Tell me the reason you came to the hospital today.
• Use back-channeling
– “All right”, ‘go on”, “uh-huh”
– “mmm”, “iya”, “lalu”, “mmhem”
PHYSICAL EXAMINATION
• INSPECTION
• AUSCULTATION
• PALPATION
• PERCUSSION
• SMELL
Observation of patients behavior
• Level of function involves a person’s ability to perform during everyday activities.
Cultural consideration in Assessment
• What do you cal your problem?
• What do you think caused your problem?
• What does your sickness do to you?
• Why do you come to me for treatment?
 • What are the most important problem your sickness has caused you?
What worries you and frightens you the most about your sickness?
Data validation
• Validate findings from physical examination and observation of patient behavior by
comparing data in the medical record and by consulting with other health team members or
even family members
• Then Do DOCUMENTATION !