NURSING ASSESSMENT

Nursing

assessment is the
first major phase in the
nursing process.
This includes Data Collection,
Data Analysis or
interpretation and problem
definition of nursing diagnosis

TWO MAJOR TYPES OF NURSING

ASSESSMENT
1. First level Assessment A process the data about
current health status of individual members, the
family as system and its environment are compared
against norms or standard of personal, social and
environment health and interaction/interpersonal
relationships within the family system
(In here, specific health conditions or problems are
identified and categorized as :

1. Wellness State

2. Health Threats

3. Health Deficits

4. Stress points or foreseeable crisis situation

TYPES OF NURSING ASSESSMENT

2.

Second Level Assessment is about

specific nursing problems that family
encounters in a given health condition, the
causes, the barriers of the familys
inability to perform health tasks, It is a
state of explanation the health
problem/wellness illness experience or
providing a home conducive to health
maintenance

THREE MAJOR STEPS IN NURSING

ASSESSMENT
1. Data Collection Involves gathering five types
of data
A. Family Structure, characteristic and dynamics
B . Socio Economic and Cultural Characteristics
C. Home and Environment
D. Health States of Each Member
E. Values and Practices in health promotion and
disease prevention
2. Data Analysis
2.1 Sub-Types of Data Analysis
a. Sorting of data

b. Clustering related cues to determine

relationships
c. distinguishing relevant from irrelevant
d. Identifying patterns
(physiologic,developmental, nutritional/dietary
coping/adaptation etc)
e. relating family data to relevant clinical
research
3. Making Diagnosis define health conditions or
problem state the reasons why the family cannot
perform such tasks.

DATA COLLECTION Nurse should identify the

kind of data needed then she/he has to select a
specific method of data gathering and the tool
needed to collect data
Types of Data:
1. Family Structure, characteristic and dynamics
Eg : Demographic data, diverging health beliefs
2. Socio- Economic and Cultural Characteristic
Eg : occupation, educational attainment, religion
3. Home and Environment- includes information on
housing and sanitation facilities, kind of
neighborhood

4. Health Status of Each member includes

current and past significant health condition or
illness, beliefs and practices
5. Values and Practices on health promotion
maintenance and disease prevention- includes
preventive services as evidenced by
immunization status, health lifestyle
Assessment Data Base (ADB)- can identify existing
and potential wellness, health threats, health
deficits, stress/ crises

DATA- GATHERING METHODS AND

TOOLS
Several methods of data gathering can be
selected depending on availability and choice ,
concerning accuracy, validity, reliability to ensure
quality assessment data combination or cross
check validation can be utilized
1. Observation done through the use of the
sensory capacities sight, hearing, smell and
touch. Direct Observation
A. communication, interaction interpersonal
relationship
B. Role perception/ task assumption
C. Conditions in the home and environment

2. Physical Examination - Health status of an

individual can be obtained through direct
examination, inspection, palpation , measurements
of body parts. Etc
3.Interview- health history determines current
health status based on past health history. It can be
collecting data by personally asking significant
family members regarding health problems.
Wellness conditions and others
4. Record Review The nurse may gather
information through reviewing records and reports
about the client includes clinical records, laboratory
and diagnostic reports/ immunization records.

5. Laboratory/ diagnostic tests- performing

laboratory/diagnostic test and others done by the people in
medical field

The assessment data base is supported and

complemented by other family assessment tool
Eg, Genograms, Ecomap and Family Life chronology
A. Genograms- is graphically display information about
family members and their relationship at least three
generations.
B. Ecomap visually diagrams the family interaction with
the environment and it resources
C. Family Life Chronology helps capture family
interactive process that have evolved Family Strengths
among others.

In order to achieve wellness and reduce health

problems, the family as functioning unit involves the
ability to perform these task :
1. Recognize the presence of wellness or health
condition or problem
2. Make decisions about taking appropriate health
action to manage health problems or maintain
wellness
3. Provide nursing care to the sick, disabled,
dependent or at risk
4. Maintain a home environment conducive to health
maintenance and personal development
5. Utilize community Resources

According to the Latter A Nursing Diagnosis

consist of two parts
1. The Statement of unhealthful response
2, The statement of factors which are
maintaining the undesirable response and
preventing the desired changes .

DATA ANALYSIS
Sorting out groups data by type of nature (eg,
wellness, threats, deficits or stress points)
Standard norms used to determine the status of
a family as client or patient
Classified into Three types :
1. Normal health of individual members
2. home and environmental condition conducive
to health development
3. Family Chracteristics, dynamics or level of
functioning conducive to family growth and
development.