Chapter 11

Assessing

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Assessment

Systematic and continuous collection, analysis,

validation, and communication of patient data
Data reflect how health functioning is enhanced by
health promotion or compromised by illness/injury.
Database includes all the pertinent patient
information collected by the nurse and other health
care professionals.
The database enables the nurse to partner with
patients to develop a comprehensive and effective
plan of care.

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Critical Thinking Activities Linked to

Assessment
Assessing systematically and comprehensively to identify
nursing and medical concerns
Detecting bias and determining the credibility of
information sources
Distinguishing normal from abnormal findings and
identifying the risks for abnormal findings
Making judgments about the significance of data,
distinguishing relevant from irrelevant data
Identifying assumptions and inconsistencies, checking
accuracy and reliability, and recognizing missing
information

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Characteristics of Nursing Assessments

Standard 1 in the ANA Scope and Standards of Practice
for nursing
Purposeful
Prioritized
Complete
Systematic
Accurate
Relevant
Recorded in a standard manner

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Four Types of Nursing Assessments

1. Initial comprehensive
2. Focused
3. Emergency
4. Time-lapsed

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Initial Comprehensive Assessment

Performed shortly after admittance to facility or service

Performed to establish a complete database for problem
identification and care planning
Performed by the nurse to collect data on all aspects of
patients health

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Focused Assessment

May be performed during initial assessment or as routine

ongoing data collection
Performed to gather data about a specific problem
already identified, or to identify new or overlooked
problems
Performed by the nurse to collect data about the specific
problem
The nurse focuses on an identifiable issue or problem

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Emergency Assessment

Performed when a physiologic or psychological crisis

presents
Performed to identify life-threatening problems
Performed by the nurse to gather data about a lifethreatening problem

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Time-Lapsed Assessment

Performed to compare a patients current status to

baseline data obtained earlier
Performed to reassess health status and make necessary
revisions in plan of care
Performed by the nurse to collect data about current
health status of patient
Performed during follow up or subsequent visits

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Establishing Assessment Priorities

Health orientation
Identify health beliefs, behaviors, risks
Developmental stage
For both children and adults
Culture
Cultural, religious, language issues
Need for nursing
Nature and length of nursing care necessary

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Medical vs. Nursing Assessments

Medical assessments target data pointing to pathologic
conditions
Nursing assessments focus on the patients response to
health problems

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Objective Data vs. Subjective Data

Objective data
Observable and measurable data that can be seen,
heard, or felt by someone other than the person
experiencing them
For example, elevated temperature, skin moisture,
vomiting
Subjective data
Information perceived only by the affected person
For example, pain experience, feeling dizzy, feeling
anxious

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Characteristics of Data

Purposeful
Type of assessment, time alloted
Complete
Gather as much information as possible
Factual and accurate
Reliable and unbiased
Relevant
Only the pertinent data

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Sources of Data

Patient
Family and significant others
Patient record
Medical history, physical examination, progress notes
Consultations
Reports of laboratory and other diagnostic studies
Reports of therapies by other health care professionals
Nursing and other health care literature

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The Skill of Nursing Observation

Determines the patients current responses (physical and

emotional).
Determines the patients current ability to manage care.
Determines the immediate environment and its safety.
Determines the larger environment (hospital or
community).

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Four Phases of a Nursing Interview

Preparatory phase
Past records, environment, timing
Introduction
Initial impression, patient comfort, establish a
rapport
Working phase
Information gathering and recording, subjective,
objective
Termination
Careful conclusion
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Purpose of a Nursing Physical Assessment

Appraisal of health status
Identification of health problems
Establishment of a database for nursing intervention

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Using Clinical Reasoning During

Assessment
Assessing systematically and comprehensively
Detecting bias and determining the credibility of
information sources
Distinguishing normal from abnormal findings and
identifying the risks for abnormal findings
Making judgments about the significance of data,
distinguishing relevant from irrelevant
Identifying assumptions and inconsistencies, checking
accuracy and reliability, and recognizing missing
information

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Problems Related to Data Collection

Inappropriate organization of the database
Omission of pertinent data
Inclusion of irrelevant or duplicate data, erroneous or
misinterpreted data
Failure to establish rapport and partnership
Recording an interpretation of data rather than observed
behavior
Failure to update the database

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When to Verify Data

When there is a discrepancy between what the person is
saying and what the nurse is observing
When the data lack objectivity
The nurse needs to verify using assessment or other
techniques

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Validating Inferences
An inference is gained from cues that the nurse reads in
the patients appearance, reporting, reactions
Inferences need to be verified as true or false
Performing a physical examination using proper
equipment and procedure
Using clarifying statements
Sharing inferences with other team members
Checking findings with research reports
Comparing cues to knowledge base of normal function
Checking consistency of cues
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Documentation of Data
Immediately give verbal reporting of data whenever a
critical change in the patients health status is assessed.
Enter initial database into computer or record in ink on
designated forms the same day patient is admitted.
Summarize objective and subjective data in concise,
comprehensive, and easily retrievable manner.
Use good grammar and standard medical abbreviations.
Whenever possible, use patients own words.
Avoid nonspecific terms subject to individual
interpretation or definition.

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