Pamantasan ng Lungsod ng Maynila

Bachelor of Science in Nursing

ASSESSMENT
A Written Report
In partial fulfillment of the course requirements in Basic Concepts in Nursing NRS 1204

Submitted to:
Professor Marilyn Agravante

Submitted by:
Nicole Ramirez
Block 1-3

Submitted on:
November 7, 2018

Semester II, S.Y. 2018 – 2019

 Table of Contents

Topic Page
A. The Patient Database 1
a. Framework for Database Collection 1
b. Patient History 3
c. Physical Examination 3
d. Laboratory and Diagnostic Studies 3
B. Organizing Information Elements 4
a. Data Collection 4
b. Data Validation 7
c. Data Clustering 7
d. Data Documentation 8
C. References 9
D. Appendices 10
a. Example of a Patient History Form 10
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Assessment
- It is the systematic and continuous collection, organization, validation, and
documentation of data. The nursing process initially depends on the complete and
accurate data gathered from assessing the patient.
Critical - Thinking Activities in Assessment
- Making reliable observations
- Distinguishing relevant from irrelevant data
- Distinguishing important from unimportant data
- Validating data
- Organizing data
- Categorizing data according to a framework
- Recognizing assumptions
- Identifying gaps in the data
The Four Types of Assessments
1. Initial Assessment – done right after admission to a health care agency to establish a
complete database for problem identification, reference and future comparison
2. Problem – focused Assessment – is integrated with nursing care to determine the status
of a specific problem identified in an earlier assessment (e.g., hourly assessment of
client’s fluid intake and urinary output in the ICU)
3. Emergency Assessment – is taken during physiological/psychological crisis to identify
the life-threatening/overlooked problems (e.g., rapid assessment of a person’s airway,
breathing status, and circulation during cardiac arrest)
4. Time – lapsed reassessment – is done after initial assessment to compare the client’s
current status from his baseline status (e.g., reassessment of functional health patterns
in a home care, outpatient, shift change in hospital)

A. The Patient Database

- It comprises all client information including:
o the nursing health history*
o physical assessment
o primary care provider’s history and physical
o results of laboratory and diagnostic tests
o material contributed from other health personnel

Framework for Database Collection

1. Gordon’s Functional Health Pattern Framework
- Marjory Gordon made use of the term pattern (a sequence of recurring behavior). The
nurse collects data about dysfunctional as well as functional behavior which helps the
nurse discern emerging patterns
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Table 1. Gordon’s Functional Health Pattern Framework

Pattern Description
Health-perception / health- management Client’s perception of health and well-
being and how health is managed
Nutritional-metabolic Client’s food and fluid consumption
relative to metabolic need and pattern
indicators of local nutrient supply
Elimination Excretory function
Activity-exercise Exercise, activity, leisure, recreation
Sleep-rest Sleep, rest, relaxation
Cognitive-perceptual Sensory-perceptual and cognitive
patterns
Self-perception / self-concept Worth, comfort, body image, feeling
Role-relationship Participation in relationships
Sexuality-reproductive Satisfaction or dissatisfaction with
partner
Coping / stress-tolerance Effectiveness of coping pattern in stress
tolerance
Value-belief Goals that guide the client ‘s choices and
decisions

2. Dorothea Orem’s Self-Care Model

- A human being who has health related /health derived limitations that render him
incapable of continuous self-care or dependent care or limitations that result in
ineffective / incomplete care. A human being is the focus of nursing only when a self –
care requisites exceeds self-care capabilities.
- Universal self-care requisites are associated with life processes and the maintenance of
the integrity of human structure and functioning.
1. The maintenance of a sufficient intake of air
2. The maintenance of a sufficient intake of water
3. The maintenance of a sufficient intake of food
4. The provision of care associated with elimination process and excrements
5. The maintenance of a balance between activity and rest
6. The maintenance of a balance between solitude and social interaction
7. The prevention of hazards to human life, human functioning, and human well-being
8. The promotion of human functioning and development within social groups in accord
with human potential, known human limitations, and the human desire to be normal

3. Roy’s Adaptive Modes

1. Physiologic mode – involves activity and rest, nutrition, elimination, fluid and
electrolytes, oxygenation, protection, regulation of the temperature, senses, endocrine
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2. Self-concept-group identity mode - focuses on psychological and spiritual integrity

and a sense of unity, meaning, purposefulness in the universe.
3. Role function mode - refers to the roles that individuals occupy in society fulfilling the
need for social integrity; it is knowing who one is, in relation to others.
4. Interdependence mode - the close relationships of people and their purpose,
structure and development individually and in groups and the adaptation potential of
these relationships.

Patient History
- Also referred to as the anamnesis of a patient is information gained by a physician by
asking specific questions, either of the patient or of other people who know the person
and can give suitable information, with the aim of obtaining information useful in
formulating a diagnosis and providing medical care to the patient.
Components of the Patient History
1. Biographic Data
2. Chief Complaint or Reason for Visit
3. History of Present Illness
4. Past History
5. Family History of Illness
6. Lifestyle
7. Social Data
8. Psychologic Data
9. Patterns of Health Care

Physical Examination
- a data collection method that uses 4 techniques:
1. Inspection – use of sense of sight and smell
2. Palpation – the pads of the fingers are used to press the skin because their
concentration of nerve endings make them highly sensitive to tactile discrimination
3. Percussion – act of striking the body to elicit sounds or vibrations, may be deep or
superficial
4. Auscultation – process of listening to sounds produced within the body, may be
done with the use of a stethoscope (indirectly) or with the unaided ear (directly)
Laboratory and Diagnostic Studies
- Diagnostic tests provide objective information about a person’s health.
- Some tests are used for risk assessment purposes—to determine the likelihood that a
medical condition is, or will become, present. Other tests are used to monitor the
course of a disease or to assess a patient’s response to treatments, or even to guide the
selection of further tests and treatments (AdvaMed 2011).
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B. Organizing Information Elements

Data Collection
- The systematic and continuous process of gathering data about a client’s health status.
Data is the qualitative or quantitative information about the client.

Types of Data
a. Subjective Data (Symptoms) – covert and can only be described and verified by the
client, it includes feelings, values, beliefs, attitude, perception of personal health and life
status (e.g., pain, feeling of worry)
b. Objective Data (Signs) – overt and detectable by an observer or measured in physical
examination. Validates client’s subjective data
c. Constant Data – information that does not change (e.g., race, blood type)
d. Variable Data – information that changes over time (e.g., blood pressure, age, amount
of pain)
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Sources of Data
- Includes primary source (the client) and secondary sources (sources other than the
client)
b. Primary Source – The Client is the best source of data unless they are too young, ill,
or confused to communicate clearly
c. Secondary Sources
i. Support People – those who know the client well enough to supplement or
verify information provided by the client
ii. Client Records – information documented by healthcare professions that
should be run through before interviewing the client, includes
1. Medical Records – provide nurses with information about the client’s
coping behaviors, health practices, previous illness or allergies (e.g.,
medical history, physical exam, operative report, consultations)
2. Therapy Records – help nurses obtain relevant data not expressed by
the client in their interactions, provided by other health professionals
such as social workers, nutritionists, dieticians, or physical therapists
(social agency report on a client’s living condition or home health care
agency report on the coping at home can help with nurse
reassessment
3. Laboratory Records – laboratory results should be compared to the
laboratory test’s norms together with client age and sex (e.g., the
blood glucose of a client determined by the lab results help monitor
the administration of hypoglycemic medication)
Note: always consider the records in the light of the present situation.
(e.g., patient’s health practices and coping behaviors are likely different
from 10 years ago)
iii. Health Care Professionals – sharing of information among professionals is
important in ensuring the continuity of patient care
iv. Literature – review of reference texts or journals to provide additional
information for the database. Includes:
1. Standards or norms against which to compare findings
2. Cultural and social health practices
3. Spiritual beliefs
4. Assessment data needed for specific client conditions
5. Nursing interventions and evaluation criteria relevant to a client’s
health problems
6. Information about medical diagnosis, treatment, prognosis
7. Current methodologies and research findings
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Data Collection Methods

a. Observation – a conscious, deliberate skill of gathering data by using the senses (vision,
smell, hearing, touch), it involves distinguishing data in a meaningful manner. Has 2
aspects:
1. Noticing the data
2. Selecting, organizing, interpreting the data
Note: Nurses need to focus on the specific data in order not to be overwhelmed by the
multitude of data. They must also develop a particular sequence for observing events,
usually focusing on the client first.
b. Interview – a planned communication or a conversation with a purpose to identify
problems of mutual concerns, teach, counsel, evaluate change (e.g., nursing health
history), has 2 approaches:
1. Directive – highly structured, the nurse establishes the purpose and controls the
flow of the interview (e.g., in an emergency situation)
2. Nondirective – rapport-building interview that allows client to control the flow
of the interview Rapport is the understanding between two or more people;
needs to be established between client and nurse

Types of Interview Questions

1. Closed questions – what, who, where questions. restrictive and generally requires
yes/no or concise answers, used in directive interviews
2. Open – ended questions – how, why questions. give clients freedom to give only the
information that they are ready to disclose, useful to elicit attitudes and longer
answers, used in nondirective interviews
3. Neutral question – client can answer without direction or pressure (e.g., “How do
you feel about that?”)
4. Leading question – directs client answer, can pressure the client and lead to
inaccurate responses (e.g., “You’re stressed about surgery tomorrow, aren’t you?”)

Planning the Interview and Setting

1. Time – nurses need to plan interviews with clients at his most convenient time of
choosing
2. Place – nurses choose a conducive setting (well-lighted, ventilated, free of noise)
3. Seating Arrangement – can be formal (parties between a table) or informal (2 chairs
placed at right angles a few feet apart)
4. Distance – accepted distance between individuals in conversation varies with
ethnicity. Proxemics is the study of the use of space.
5. Language – medical jargons should be converted in layman terms, interpreters may
be needed if there is a language barrier. Issues of confidentiality or gender mismatch
may interfere with effective communication.
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Stages of an Interview
1. The Opening – sets the tone for the whole interview, the purpose is to establish
rapport (greeting with handshake or smile) and orientation (explains purpose and
nature of interview)
2. The Body – the nurse should use effective communication techniques to keep the
conversation flowing
3. The Closing – important for maintaining the rapport for facilitating future
interactions. Nurse terminates interview once enough data is obtained or when
client can no longer provide needed data
c. Examination – also referred to as physical examination/physical assessment, systematic
data collection method using observation. Uses 4 techniques:
1. Inspection
2. Palpation
3. Percussion
4. Auscultation

The 2 Examination Approaches

1. Cephalocaudal / Head – to – toe approach – from the head to the lower extremities
2. Body Systems approach – investigates each system individually

Screening examination / review of systems – a brief review of essential functioning of

various body parts or systems

Data Validation
- Act of double-checking or verifying data to confirm that it is accurate and factual. This
helps in differentiating cues from inferences. Cues are subjective or objective overt data
that the client say or what the nurse measures. Inferences are the nurse’s interpretation
based on the cues
- Only done when there are discrepancies in data gathered from the interview, physical
examination, client statements that changes in the assessment

Data Clustering
- Written (or computerized) format that organizes the assessment data systematically,
referred to as the nursing health history, nursing assessment, nursing database form\
- the grouping of related information from a patient's health history, physical
examination, and laboratory results
- Recognizing a pattern or trend; comparing the data with standards and, making a
conclusion
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Data Documentation
- Accurate documentation is essential and should include all data collected about the
client’s health status. Record subjective data in client’s own words in quotes, and the
nurse’s objective data in medical terms
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Resources
AdvaMed. (2011). Categories of Diagnostic Tests. Policy Primer on Diagnostics. Retrieved on 5 November
2018 from https://dx.advamed.org/sites/dx.advamed.org/files/resource/advameddx-policy-
primer-on-diagnostics-june-2011.pdf

Berman, A. et al. (2008). Kozier and Erb’s Fundamental of Nursing. 8th Ed. Vol. 1. New Jersey, NJ: Pearson
Education, Inc.

Dorotea Orem’s Self-Care Theory. (2012). Nursing Theories. Retrieved on 5 November 2018 from
http://currentnursing.com/nursing_theory/self_care_deficit_theory.html

Gonzalo, A. (2011). Sister Callista Roy’s Adaptation Model. Nursing Theories. Retrieved on 5 November
2018 from http://nursingtheories.weebly.com/sister-callista-roy.html

John Hopkins Medicine. (n.d.). Patient History Form. Retrieved on 5 November 2018 from
https://www.hopkinsmedicine.org/psychiatry/.../patient.../pt_medi_history_form.doc
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Appendix
a. Example of Patient History Form

PATIENT HISTORY FORM

Date: _______/_________/________

NAME: Birthdate: _____/______/_____

Last First M. I.

Age:___________ Sex:  F  M

How did you hear about this clinic?

Describe briefly your present symptoms:

Please list the names of other practitioners you have seen for this problem:

Psychiatric Hospitalizations (include where, when, & for what reason):

Have you ever had ECT? Have you had psychotherapy?

CURRENT MEDICATIONS

Drug allergies:  No  Yes To what?

Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements:

Name of drug Dose (include strength & number of pills per day) How long have you been taking this?

1.

12 Physician initials
_______
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2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13 Physician initials
_______
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PAST MEDICAL HISTORY

Do you now or have you ever had:

 Diabetes  Heart murmur  Crohn’s disease

 High blood pressure  Pneumonia  Colitis

 High cholesterol  Pulmonary embolism  Anemia

 Hypothyroidism  Asthma  Jaundice

 Goiter  Emphysema  Hepatitis

 Cancer (type) _________________  Stroke  Stomach or peptic ulcer

 Leukemia  Epilepsy (seizures)  Rheumatic fever

 Psoriasis  Cataracts  Tuberculosis

 Angina  Kidney disease  HIV/AIDS

 Heart problems  Kidney stones

Other medical conditions (please list):

PERSONAL HISTORY

Were there problems with your

birth? (specify)

Where were your born & raised?

What is your highest education? High school Some college College graduate Advanced degree

Marital status:  Never married  Married  Divorced  Separated  Widowed  Partnered/significant other
What is your current or past occupation?

Are you currently working? :  Yes  No Hours/week ______ If not, are you  retired  disabled  sick leave?

Do you receive disability or SSI?  Yes  No If yes, for what disability & how long?___________________________

Have you ever had legal problems? (specify)

Religion:

14 Physician initials
_______
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FAMILY HISTORY

IF LIVING IF DECEASED

Age (s) Health & Psychiatric Age(s) at death Cause

Father

Mother

Siblings

Children

EXTENDED FAMILY PSYCHIATRIC PROBLEMS PAST & PRESENT:

Maternal Relatives:

Paternal Relatives:

15 Physician initials
_______
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SYSTEMS REVIEW

In the past month, have you had any of the following problems?

GENERAL NERVOUS SYSTEM PSYCHIATRIC

 Recent weight gain; how much____  Headaches  Depression

 Recent weight loss: how much____  Dizziness  Excessive worries
 Fatigue  Fainting or loss of consciousness  Difficulty falling asleep
 Weakness  Numbness or tingling  Difficulty staying asleep
 Fever  Memory loss  Difficulties with sexual arousal
 Night sweats  Poor appetite

 Food cravings
MUSCLE/JOINTS/BONES STOMACH AND INTESTINES  Frequent crying
 Numbness  Nausea  Sensitivity
 Joint pain  Heartburn  Thoughts of suicide / attempts
 Muscle weakness  Stomach pain  Stress
 Joint swelling  Vomiting  Irritability
Where?  Yellow jaundice  Poor concentration

 Increasing constipation  Racing thoughts

EARS  Persistent diarrhea  Hallucinations
 Ringing in ears  Blood in stools  Rapid speech
 Loss of hearing  Black stools  Guilty thoughts

 Paranoia
EYES SKIN  Mood swings
 Pain  Redness  Anxiety
 Redness  Rash  Risky behavior
 Loss of vision  Nodules/bumps
 Double or blurred vision  Hair loss
 Dryness  Color changes of hands or feet OTHER PROBLEMS:

THROAT BLOOD

 Frequent sore throats  Anemia

 Hoarseness  Clots

16 Physician initials
_______
 15

 Difficulty in swallowing

 Pain in jaw KIDNEY/URINE/BLADDER

 Frequent or painful urination

HEART AND LUNGS  Blood in urine
 Chest pain

 Palpitations Women Only:

 Shortness of breath  Abnormal Pap smear

 Fainting  Irregular periods

 Swollen legs or feet  Bleeding between periods

 Cough  PMS

WOMENS REPRODUCTIVE HISTORY:

Age of first period:

# Pregnancies:
# Miscarriages:
# Abortions:
Have you reached menopause? Y / N At what age?
Do you have regular periods? Y/ N

17 Physician initials
_______
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SUBSTANCE USE

DRUG CATEGORY
Age when When did Do you currently
How much & How many
you first how often did years did you you last use this?
(circle each substance used) you use this? use this?
used this:
use this?

ALCOHOL Yes □ No □

CANNABIS: Yes □ No □
Marijuana, hashish, hash oil

STIMULANTS: Yes □ No □
Cocaine, crack

STIMULANTS: Yes □ No □
Methamphetamine—speed, ice, crank

AMPHETAMINES/OTHER STIMULANTS:
Yes □ No □
Ritalin, Benzedrine, Dexedrine
BENZODIAZEPINES/TRANQUILIZERS:
Yes □ No □
Valium, Librium, Halcion, Xanax, Diazepam,
“Roofies”
SEDATIVES/HYPNOTICS/BARBITURATES:
Yes □ No □
Amytal, Seconal, Dalmane, Quaalude,
Phenobarbital
HEROIN
Yes □ No □

STREET OR ILLICIT METHADONE Yes □ No □

OTHER OPIOIDS:
Yes □ No □
Tylenol #2 & #3, 282’S, 292’S, Percodan,
Percocet, Opium, Morphine, Demerol,
Dilaudid
HALLUCINOGENS:
Yes □ No □
LSD, PCP, STP, MDA, DAT, mescaline,
peyote, mushrooms, ecstasy (MDMA),
nitrous oxide
INHALANTS:
Yes □ No □
Glue, gasoline, aerosols, paint thinner,
poppers, rush, locker room

18 Physician initials
_______
 19 Physician initials
_______