Nursing Process: Nursing Assessment

George Ann Daniels, MS, RN

Assessment
Continuous and systematic collection, validation, and communication of client data .(Harrington, 1996)

Assessment
Purpose: Collect, validate and organize data about a clients state of wellness, functional ability, physical status, strengths, and responses to actual and potential health problems. Initial, focused, time-lapsed and emergency assessment are done depending on the circumstances

Essential pre-assessment activities

Choose a framework for assessment and documentation

Gordons functional health patterns

Control the environment Work on assessment skills

Observation Interviewing Physical exam Intuitions

Types of Data
Subjective: facts presented by the client that show his/her perception Objective: facts that are observable and measurable by the nurse, involves use of the senses

Seeing Hearing Smelling Touching

Cues

A word used to describe the individual pieces of data or hints about what is going on with the client

Also called assessment findings

Cues are analyzed to arrive at appropriate NDX

Sources of Data

Primary: from the client, considered the most reliable if the client is deemed a good historian

Nursing judgment

Secondary: significant others, the medical or health record, lab tests, diagnostic procedures, meds, past medical HX, other health team members, and literature review Data needs to be validated

Organization of Data
Need to use an organized assessment framework to help cluster assessment data (cues)into meaningful groups RSU uses Gordons Functional Health Patterns

Health Perception-Health Management

Clients awareness of personal health and well-being; health practices; understanding of how health practices contribute to health status To assess this pattern, focus on a general survey of the clients health status and their usual health behaviors

Nutritional-Metabolic Pattern
Patterns of food and fluid intake, relationship of intake to metabolic needs; skin assessment, fluid volume, thermoregulation To assess this pattern, focus on eating habits, appraisal of appetite, weight loss or gain, changes in skin, hair,or nails.

Elimination Pattern
Patterns of excretory function (Bowel, Bladder,and Skin), and client perception of same Assess usual bowel and bladder elimination habits,laxative use, excretory function of skin (e.g. excessive perspiration)

Activity -Exercise
Patterns of exercise, activity, leisure recreations, and ADL; factors that interfere with desired or expected individual pattern Assess mobility status, exercise routine, leisure activities, cardiovascular status

Sleep- Rest pattern

Patterns of sleep and rest-relaxation periods during 24 hour day. As well as quality and quantity Assess regular sleep habits and routine

Cognitive-Perceptual Pattern
Adequacy of sensory modes, such as vision, hearing taste, touch, smell, pain perception, cognitive functional activities Assess changes in cognitive function, ability to hear, see, and speak, presence of pain, numbness, or other sensations

Self-perception- Self-concept Pattern

Individuals attitudes about self, perception of abilities, body image, identity, general sense of worth and emotional patterns Assess descriptions of self, physical appearance, effects of illness, major life accomplishments and changes

Role- Relationship Pattern

Client's perception of major roles and responsibilities in current life situation Assess client's perceptions of key relationships, observation of interactions with others

Sexuality-Reproductive Pattern
Client's perceived satisfaction or dissatisfaction with sexuality. Reproductive stage and pattern Assess clients appraisal of his or her sexual role and sexual health.

Coping-Stress Tolerance Pattern

General coping pattern, stress tolerance and management, support systems, and perceived ability to control and manage situations Assess current stress level, coping ability, ability to endure life stressors, physiologic responses to stress

Value- Belief Pattern

Values, goals, or beliefs that guide choices or decisions. Assess identification of valued people and possessions, source of support, religious practices

Measurement Criteria for ANA

Standard I: Assessment: The nurse collects client health data

Data collection involves client, significant others, and healthcare providers when appropriate The priority of data collection activities is determined by the clients immediate condition or needs

Pertinent data are collected using appropriate assessment techniques and instruments Relevant data are documented in a retrievable form The data collection process is systematic and ongoing