ASSESSMENT

What?
It is the collection of subjective
and objective data (e.g., vital
signs, patient/family interview,
physical exam) and
review of historical information
provided by the patient/family,
or found within the patient chart.
Nursing Process
• Assessment (gather subjective and objective data,
family history, surgical history, medical history,
medication history, psychosocial history)
• Analysis or diagnosis (formulate a nursing diagnosis
by using clinical judgment; what is wrong with the
patient)
• Planning (develop a care plan which incorporates
goals, potential outcomes, interventions)
• Implementation (perform the task or intervention)
• Evaluation (was the intervention successful or
unsuccessful)
 The function of a nursing
assessment
• to identify the assessment parameters and
responsibilities needed to plan and deliver appropriate,
individualized care to the patient.
This includes documenting:
• Appropriate level of care to meet the client's or patient’s
needs in a linguistically appropriate, culturally competent
manner
• Evaluating response to care
• Community support
• Assessment and reassessment once admitted
• Safe plan of discharge
 Summary Nursing Admission Assessment
1. Documentation: Name, medical record number, age,
date, time, probable medical diagnosis, chief complaint,
the source of information (two patient identifiers)
2. Past medical history: Prior hospitalizations and major
illnesses and surgeries
3. Assess pain: Location, severity, and use of a pain scale
4. Allergies: Medications, foods, and environmental;
nature of the reaction and seriousness; intolerances to
medications; apply allergy band and confirm all
prepopulated allergies in the electronic medical record
(EMR) with the patient or caregiver
 Summary Nursing Admission Assessment
5. Medications: Confirm accuracy of the list, names, and dosages
of medications by reconciling all medications promptly using
electronic data confirmation, if available, from local
pharmacies; include supplements and over-the-counter
medications
6. Valuables: Record and send to appropriate safe storage or
send home with family following any institutional policies on
the secure management of patient belongings; provide and
label denture cups
7. Rights: Orient patient, caregivers, and family to location,
rights, and responsibilities; goal of admission and discharge
goal
8. Activities: Check daily activity limits and need for mobility aids
9. Falls: Assess Morse Fall Risk and initiate fall precautions as
dictated by institutional policy
 Summary Nursing Admission Assessment
10. Psychosocial: Evaluate need for a sitter or video
monitoring, any signs of agitation, restlessness,
hallucinations, depression, suicidal ideations, or substance
abuse
11. Nutritional: Appetite, changes in body weight, need for
nutritional consultation based on body mass index (BMI)
calculated from measured height and weight on admission
12. Vital signs: Temperature recorded in Celsius, heart rate,
respiratory rate, blood pressure, pain level on admission,
oxygen saturation
13. Any handoff information from other departments
 Physical Exam
1. Cardiovascular: Heart sounds; pulse irregular, regular,
weak, thready, bounding, absent; extremity coolness;
capillary refill delayed or brisk; presence of swelling,
edema, or cyanosis
2. Respiratory: Breath sounds, breathing pattern, cough,
character of sputum, shallow or labored respirations,
agonal breathing, gasps, retractions present, shallow,
asymmetrical chest rise, dyspnea on exertion
3. Gastrointestinal: Bowel sounds, abdominal tenderness,
any masses, scars, character of bowel movements, color,
consistency, appetite poor or good, weight loss, weight
gain, nausea, vomiting, abdominal pain, presence of
feeding tube
 Physical Exam
4. Genitourinary: Character of voiding, discharge, vaginal bleeding
(pad count), last menstrual period or date of menopause or
hysterectomy, rashes, itching, burning, painful intercourse, urinary
frequency, hesitancy, presence of catheter
5. Neuromuscular: Level of consciousness using AVPU (alert, voice,
pain, unresponsive); Glasgow coma scale (GCS); speech clear,
slurred, or difficult; pupil reactivity and appearance; extremity
movement equal or unequal; steady gait; trouble swallowing
6. Integument: Turgor, integrity, color, and temperature, Braden
Risk Assessment, diaphoresis, cold, warm, flushed, mottled,
jaundiced, cyanotic, pale, ruddy, any signs of skin breakdown,
chronic wounds
 Initial Assessment
Steps in Evaluating a New Patient
1. Record chief complaint and history
2. Perform physical examination
3. Complete an initial psychological evaluation; screen for
intimate partner violence; CAGE questionnaire and
CIWA (Clinical Institute Withdrawal Assessment for
Alcohol) scoring if indicated; suicide risk assessment
4. Provide a certified translator if a language barrier
exists; ensure culturally competent care and privacy
5. Ensure the healthcare provider has ordered the
appropriate tests for the suspected diagnosis, and
initiate any predetermined protocols according to the
hospital or institutional policy
Which provides the diagnosis most often:
history, physical, or diagnostic tests?
• History: 70%
• Physical: 15% to 20%
• Diagnostic tests: 10% to 15%
 History Taking Techniques
• P: What provokes symptoms? What improves or
exacerbates the condition? What were you doing when it
started? Does position or activity make it worse?
• Q: Quality and Quantity of symptoms: Is it dull, sharp,
constant, intermittent, throbbing, pulsating, aching,
tearing or stabbing?
• R: Radiation or Region of symptoms: Does the pain travel,
or is it only in one location? Has it always been in the
same area, or did it start somewhere else?
• S: Severity of symptoms or rating on a pain scale. Does it
affect activities of daily living such as walking, sitting,
eating, or sleeping?
• T: Time or how long have they had the symptoms. Is it
worse after eating, changes in weather, or time of day?
 S-A-M-P-L-E
• S: Signs and symptoms
• A: Allergies
• M: Medications
• P: Past medical history
• L: Last meal or oral intake
• E: Events before the acute situation
 Pain Assessment
Indicators of Pain
1. Restlessness or pacing
2. Groaning or moaning
3. Crying
4. Gasping or grunting
5. Nausea or vomiting
 Pain Assessment
Indicators of Pain
6. Clenching of the teeth and facial expressions
7. Tachycardia or blood pressure changes
8. Panting or increased respiratory rate
9. Clutching or protecting a part of the body
10. Unable to speak or open eyes
11. Decreased interest in activities, social gatherings, or old
routines
 Assessment tools
1. Activities of daily living scale
2. Cough assessment
3. Health questionnaires such as those that address recent
travel and exposure risks
4. Waterlow or Braden scale for assessing pressure ulcer
risk
5. Glasgow coma scale/AVPU for assessment of
consciousness
6. Pain scales such as the Faces Pain Scale (FPS), Numeric
Rating System (NRS), Visual Analogue Scales (VAS),
Wong-Baker Faces Pain Rating Scale (WBS), and the
(MPQ) McGill Pain Questionnaire
 Equipment
1. The nurse should be familiar with the
otoscope, penlight, stethoscope (bell and
diaphragm), thermometer, bladder
scanner, speculum, eye charts, cardiac
and blood pressure monitors, fetal
doppler and extremity doppler, and
sphygmomanometer
2. Stretcher or bed for proper positioning
during a physical exam
3. Hand hygiene products, personal
protective equipment if required
 Equipment
4. Alcohol swabs, sanitizer, or soapy water to
clean equipment after use, such as with
stethoscopes, to decrease the likelihood of
cross-contamination of pathogens from
inanimate objects (follow any manufacturer
guidelines or institutional policies)
5. Computer or paper chart to document findings
6. Calculation devices for BMI, conversion from
pounds to kilograms, kilograms to pounds,
Celsius to Farenheight