ASSESSMENT

Nursing process is a systematic method that directs the nurse and patient·s together to accomplish the following. (i) Assess the patient to determine the need for nursing care. (ii) Determine the nursing diagnosis for actual and potential health problems. (iii) Identify expected outcomes and plan care. (iv) Implement the care. (v) Evaluate the results.

Definition:
The Nursing process is used to identify, diagnose and treat human responses to health and illness. (By ANA)

Nursing Process an Overview:
Assessment Gather information about client¶s condition.

Evaluation Determine if goals met and outcomes achieved.

Diagnosis Identify the client¶s problems.

Implementation Perform the nursing actions as per the planning.

Planning  Set goals of care and desired outcomes.  Identify the appropriate nursing actions.

Nursing process is a continuous process which involves the following five series of steps. (i) (ii) (iii) (iv) (v) Assessment Planning Diagnosis Implementation Evaluation.

Nursing Assessment
It is the first phase of nursing process.

Definition
Nursing Assessment is the systematic and continuous collection, validation and communication of patient·s data. Nursing Assessment is the gathering of information about a patient·s physiological, psychological, sociological and spiritual status.

Purposes of Nursing Assessment
o To gather data about the individual, family or community. o To establish the base line information about the client. o To determine the client·s normal function. o To determine the presence or absence of dysfunction. o To determine the client·s risk for dysfunction. o To determine the client·s strengths. o To identify the actual and potential health problems. o To provide data for the diagnosis phase.

Types of Nursing Assessments
(i) Initial Assessment

It is performed shortly after the patient is admitted to the hospital. Here the nurse gathers the information about all aspects of the patient·s health status. This information is otherwise called Base line data. It tells about the

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patient·s condition before investigations begin and it serves as the basis for identifying the problems.
Purpose Œ

It is done to establish a complete data base for problem identification and care planning.

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The nurse collects data related to all the aspects of patient·s health.

(ii) Focused Assessment

The nurse gathers data about a specific problem that has already been identified. It is used to gather information that is specific to determine the status of an actual or potential problems. It is an ongoing assessment, helps to identify an actual or potential problems. The nurse has to perform periodic focus assessment to monitor the status. The questions may be
j What ate the symptoms? j When did they start? j What makes the symptoms better or worse? j Whether the client takes any remedies (Medical/Natural) for the

symptoms?
Purpose

The purpose of the Focused Assessment is to identify new or over looked problems.
Guidelines to be followed while performing focus assessment

1. Are these observable signs and symptoms that demonstrate that the problem exists right now? Are these symptoms getting better, worse or staying the same? 2. Are there factors contributing to the problem that can be reduced, controlled or eliminated to alleviate or prevent the problem? 3. How does the patient feel about managing or preventing the problem?

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It is done mostly to the patients in residential settings and those who received nursing care over a prolonged period of care. It is used to detect the changes in all functional health patterns. Medical Assessment j Targeting data pointing out to pathological conditions. There is a several months gaps between the two assessments.g. (iv) Time Lapsed Assessment It is performed to compare a patient·s current status to base line data obtained earlier. It is done for the patients 1. Purpose To re assess health status and to make necessary revisions in patient care. Who have difficulties involve Airway. Uniqueness of Nursing Assessment: When nurses performing assessment they should not duplicate the medical assessment. Emergency assessment takes place in life threatening situations when the preservation of life is in the top priority. Suicidal thoughts Emergency assessment focuses on a few essential health patterns and it is not a comprehensive assessment. Purpose To identify life threatening problems. 4 .(iii) Emergency Assessment This is performed by the nurse when there is a physiological or psychological crisis (e. violence). Breathing and circulation 2.

Data collection begins when the client approaches the health care system in first time.Nursing Assessment j Focus on the patient·s responses to actual or potential health problems. Steps in the Nursing Assessment (i) Collecting data. Factual and Accurate While collecting the data the nurse should continually verify what she hear. time lapsed) and gather the data. (iv) Identifying patterns. The nurse should check the data provided by the patient 5 . using other senses and validating all questionable data. (i) Collecting data Gathering information about patient or client. a comprehensive nursing assessment is accomplished. and pertinent data are documented in the chart. with what she observe. (iii) Organizing data. This could be collected from the out patient department it self. Characteristics of data Purposeful The nurse should identify the purpose of the nursing assessment (comprehensive. (ii) Validating data. At the time of admission. (v) Communicating/Recording data. Complete The nurse should collect the complete data needed to understand the patient health problem and to develop the nursing care plan. emergency. focused.

Resources for Data Collection º º º º º º º º Patient/client (primary source). Verbal/written consultations (with other health care professionals). It is best that the assessor should document the observed behaviour rather than the interpreted behaviour. Types of data (a) Subjective data Information perceived only by the affected person. Medical records. Nursing records. Attempts to engage him in conversation fail. Interpreted behaviour . Observed behaviour .g. E. Records of diagnostic studies. Feeling of nervousness.g.or care giver is reliable. pain. (b) Objective data Observation or measurement made by the observer. 6 . Relevant literature.Patient is depressed Relevant During collection of data the nurse should determine what type of data and how much data need to be collected from the patients. Family/significant members.Patient frequently observed lying with his face to the wall. He refused lunch today and ate only soup for dinner. nausea. Nurse·s experience. E.

Establish a therapeutic relationship with the client. Determine the client·s goals and expectations of the health care system. etc. Nurse can explain her role and the role of others during the care to the client.E. Wound assessment. Termination Phase 7 . Advantages of an interview 1. 4. 5. Obtain cues about which parts of the data collection phase require further in-depth investigation. Centimeter on measuring tape. Interview It is the first step to collect the subjective information from the client. Blood pressure. y y y Fahrenheit or Celsius thermometer.g. Gain insight about the client·s concerns and worries. Preparatory/orientation Phase: 2. 6.g. Establish a sense of carry for the client as an individual. localized body rash. The measurement of the objective data is based on an accepted standard. identification of temperature. Interview is an organized conversation with the client to obtain the client·s health history and information about the current illness. 2. 3. E. Working Phase 3. Phases of Interview 1.

Preparatory / Orientation Phase y Before starting interview. y The nurse should initiate the interview by stating her Name & Status and the purpose of interview. summarizing and clarifying and her critical thinking skills. In this phase the nurse should use a variety of communication skills such as listening. Working Phase During this phase the nurse gathers all information about the client·s health status. Summarize all the important points and check with the client that the summary is accurate. The seating arrangements and the distance between the patient and nurse should be adequate.1. y Nurse should approach the patient·s with open mind and to be sensitive to the human needs. Tips for an successful Interview To establish a rapport  Ensure privacy  Use the person·s name  Explain your purpose  Use good eye contact  Don·t hurry 8 . 2. focusing. y Interview should be completed in a friendly manner. the nurse prepares to meet the patient·s by reading current and past records and reports. y y Ensure that the environment is private and relaxed. Termination Phase y y Nurse should give clue that the interview is going to end. 3. paraphrasing. y Assure the patient about the confidentiality.

spiritual health. socio cultural history. family and health history. Taking nursing history prior to the physical examination allows a nurse to establish a rapport with the patient and helps to gain the confidence of the patient. 9 .To observe  Use your senses  Notice general appearance  Notice body language  Notice Interaction Patterns To ask questions  Ask about the person·s main problem first  Use the terminology that the person understands  Use open ended questions  Use reflection  Don·t start with personal or delicate questions  Use an organized assessment tool to prevent omissions To Listen  Be an active listener  Allow the person to finish sentences  Be patient if the person has a memory block  Give your full attention  For clarification. including a review of body systems. summarize and restate what has been said Components of Data Collection • Nursing history. • Physical/psychological examination. mental and emotional reactions to illness. Nursing History Nursing history is a data collected about the client·s current level of wellness.

10 . Religious experiences. Community resources. Primary language. Educational level.Dimensions for Health History Physical and developmental o Perception of health status  Past health problems/therapies  Risk factors. Cultural influences.  Review of systems. Attention span.  Self concept.  Coping mechanisms. Recreational activities. Social Financial status. Fellowship.  Social relationships. Environmental risk factors.  Developmental stage.      Spiritual Beliefs and meaning.  Ability to complete activities of daily living (ADL). Long term and recent memory.  Sexuality.  Activity and coordination.  Family structure and support. Rituals and practices.  Body image.  Growth and malnutrition. Emotional  Behavioral and emotional status.  Support systems.  Mood. Communication patterns. Problem solving.  Occupation.       Client Health History       Intellectual Intellectual performance. Courage.

Date of Surgery 16. Language Known : Illiterate/primary/High School/College : : : Hindu/Muslim/Christian/Others (Specify) : Tamil/Hindi/Malayalam/Kannada/Telugu English/Others (Specify) 12. Income 10. Diagnosis 14. Occupation 9. Age 3.Components of a Nursing History I. Ward 5. Marital Status : : «««««««Year : Male / Female : : : Single/Married/Separated/ Divorced/Widowed 7. Address 13. Post O. Education 8. Religion 11. IP No 6. Date of Admission 15. Name 2. Informant : : : : : : : : 11 .P. Sex 4. Nature of Surgery 17. Day 18. Date of Discharge 19. Biographic data 1.

diabetes. IV. cancer.II. arthritis. obesity. Family Health History Patient (a) Family Composition S. Is he/she living in rented house or own house/ No. tuberculosis. of rooms. windows/water facility/electricity facility/toilet facility/income of the family/bread winner of the family/drainage facility. Introduction III. 12 . and any mental health disorders. doors. Socio Economic Background Write whether patient is from a village/town/city. kitchen garden and pet animals. parents. bleeding. and grand parents and their current state of health or (if they are deceased) the cause of death are obtained. Particular attention should be given to disorders such as heart disease. No Name Relationship Age Sex Education Occupation Health to patient Status (b) Family Medical History To ascertain risk factors for certain diseases the ages of siblings. hypertension. alcoholism. allergies.

cigarette smoking. brushing. alcohol. Personal History (a) Personal Habits The amount. cola. wake times. (e) Elimination Bowel habits Bladder habits (f) Hobbies/Interests Reading books/Watching TV/Playing/Listening to music/Others (Specify) Number of times per day Number of times during day and night 13 . elimination. grooming.V. bathing. coffee. and duration of substance use (tobacco chewing. difficulties sleeping. and locomotion. tea) (b) Diet Number of meals and snacks/day Vegetarian/Non Vegetarian Allergies to any food item Nutritional assessment 24 hours recall and recommended diet plan (for patients on therapeutic diet) Likes & Dislikes of food (c) Sleep/Rest Patterns Usual daily sleep/number of hours per day & night. and remedies used for difficulties. dressing. frequency. (d) Activities of daily living Any difficulties experienced in the basic activities of eating.

number of death. Regular/Irregular 5. name of surgeon.(g) Menstrual History 1. Any pain (h) Obstetrical History Number of pregnancy. Any abnormalities 6. History of Present Illness (a) Present Medical History When the symptoms started Whether the onset of symptoms were sudden or gradual How often the problem occurs Exact location of the distress Character of the complaint (e. Duration of cycle 3. any complications. : : : : : : VI.g. number of delivery. Amount of flow 4. number of live child. still birth. Puberty attained on 2.. abortion. events and its outcome. intensity of pain or quality of sputum. 14 . client¶s reaction. emesis or discharge) Activity in which the client was involved when the problem occurred Phenomena or symptoms associated with the chief complaint Factors that aggravate or alleviate the problem (b) Present Surgical History Date and type of procedure performed.

Techniques of Physical Assessment Inspection Inspection is the systematic. Nurses Physical Assessment . smell and touch to detect health problems. color.VII. Inspection should be conducted in a well 15 . texture. History of Past Illness (a) Past Medical History Previous hospitalization (medical/surgical) Any communicable disease/genetic disorders On treatment for any disease Immunization if any Allergies: H/O any drug allergy (b) Past Surgical History/Present Surgical History Nature of Surgery Date of Surgery Name of Surgeon Physical Assessment The physical examination is a systematic data collection method that uses the senses of sight. Physician Physical Assessment . hearing. deliberate visual examination of the entire body region.To identify pathologic conditions and their causes. position and deformities. symmetry. Neurological deficit. Inspection gives information about size. shape. eg.Focuses primarily on the patients functional abilities.

prolonged pressure can cause injury to the internal organs. 1. The nurse can trap the structures that move between the two hands. tissue firmness and elasticity. consistency and mobility. Example palpation of kidney while respiration. tongue plate. breast and uterus. kidney. shape. exert varying amounts of pressure to determine information about masses. various specula (nasal and vaginal) etc. 16 . marking pen. 2. vibration. organ size. Palpation is also done to assess masses for position. Levels of Palpation: Light Palpation: Depress the underlying tissue approximately 1 to 2 cm. palpate tender areas last. pulsation. The patient should be placed in a comfortable position. By using this method the nurse can able to identify the variations in liver. skin fold. We can find out the variation by positioning one hand or stabilizes on organ while other hand palpates. tenderness or pain. swelling. During palpation. opthalmoscope. calipers and eye charts) Palpation It is one method of physical assessment performed by use of touch. ask the patient to indicate tender areas. temperature and moisture. spleen.lighted setting. size. Bi-Manual Palpation: Place one hand lightly on the client·s skin (the sensing hand) place the other hand (active hand) over the sensing hand to apply pressure. proceeding cautiously. Before palpating. The sensing hand does not apply direct pressure and remains sensitive to underlying organ characteristics. tape measure. Deep Palpation: Depress the underlying tissue approximately 4 to 5 cms. otoscope. It is enhanced with special instruments such as penlight.

5.g. abdomen and vascular system are commonly assessed by using stethoscope. depending on density. short sound produced by very dense tissue such as muscle. Flatness A soft. pulmonary emphysema. Dullness A soft to moderately loud sound of moderate pitch and duration.. Resonance It is a moderate to loud. Hyperresonance: It is a very loud low pitched sound with longer duration than resonance produced by the over inflated. high pitched. Auscultation: Auscultation is listening to internal body sounds to assess normal sounds and detect abnormal sounds. 3. lungs. 17 . 4. air containing structures. high pitch long sound with a drum like musical quality results from enclosed. Tympany: It is a loud. 2. Percussion: This is used to assess tissue density with sound produced from striking the skin. E. Types of sounds: 1. It produced by less dense mostly fluid tissue such as liver and spleen.Precautions: Do not palpate the carotid or arteries simultaneously because there is a possibility of restricting the blood flow to the brain. Percussion of body structures containing a. such as the stomach (gastric bubble) and bowel. low pitch sound with long duration results from the air filled tissue of the normal lungs. fluids and solids produces various sounds. The sounds produced by heart. air filled lungs of the person.

2.Characteristics of Auscultation sounds: Pitch: The number or frequency of sound wave cycles per second. 18 .. Chronic bronchitis. blowing.. E. Discontinuous popping sounds heard in early inspiration. Duration: It may be long.g. Pulmonary oedema. The greater amplitude results the louder sound where as the lower amplitude results softer sound. harsh. high pitched. Chronic bronchitis. medium or short.. originates in the alveoli. Soft. Fine crackles. E. Discontinuous popping sounds heard in late inspiration. Coarse crackles. High frequency results in high pitched sound. discontinuous popping sounds that occur during inspiration. 3. Quality: It is the description of a sound·s character such as gurgling. E. emphysema. moist sound originating in the large bronchi. Intensity: It is the amplitude of a sound wave. Crackles in general.g. sounds like hair rubbing together. Abnormal (Adventitious breath sounds): Crackles: 1.g. whistling or snapping. where as low frequency produces low pitched sound.

pneumonia 2. then a temporary vibration may occur in diastole that is similar to... E. E. Left ventricular failure. Abnormal Cardiac Sounds Gallop. low pitch ending in late diastole. Third heart sound (s3). although usually softer than s1 and s2. Cystic fibrosis. Continuous. cracking sound like two pieces of leather being rubbed together. low pitched. Rhonchi. musical. Left ventricular hypertrophy. low pitched rumpling sounds heard primarily during expiration.g.g. Heard during inspiration alone or during both inspiration and expiration. similar to sound of a gallop. Extra heart sound. Pleural Friction Rub: Harsh. pulmonary stenosis. Fourth heart sound (s4).. Stridor. It may subside when patient holds breath. as occurs in certain disease states. Deep.Wheezes: 1. epiglottitis. E.g. mitral valve regurgitation. high pitched whistle like sounds heard during inspiration and expiration caused by air passing through narrowed or partially abstracted air ways.g. pneumonia.. ending in early diastole. 19 . If the blood filling the ventricle is impeded during diastole. Extra heart sound. Croup syndrome.. E. Pulmonary infarct. may clear with coughing. E.g. caused by air moving through narrowed tracheobronchial passages. COPD.

Don¶t relay on memory ± takedown notes for better accuracy Use the assessment tool available in the organization Physical Assessment Format General Appearance Nourishment Body Build Hygiene and Grooming Activity Health Posture Movement : Clean/Neat/Dirty/Unkempt (not combed properly) : Active/Dull : Healthy/Unhealthy : Normal posture/Lordosis/Kyphosis/Scoliosis : Coordinated movement/Tremors/Uncoordinated movement : Well nourished/Moderately Nourished/Malnourished : Thin/Moderate/Obese 20 . Friction Rub.. Turbulent sounds occurring between normal heart sounds..Cardiac Murmurs. Pericardits. Guidelines for Performing Physical Assessment Provide Privacy Establish Rapport and use good interviewing techniques rather than working in silence. grating sound that can be heard in both systole and diastole is called friction rub.g. Cardiac valve disorder. E.g. E. A harsh.

oC/««««.cms : ««««««. Head Shape : Oriented to time place and person ««««..kgs : Normal//macrocephalic/ hydrocephalic /micro cephalic Scalp Face : Clean/presence of dandruff/pediculi : Pale/flushed/puffiness/fear/anxiety/enlargement of parotid Glands/ symmetric Subjective Symptoms : 21 .oF ««««««beats/minute ««««««breaths/minute ««««««mm of Hg : : : : : ««««««.Mental Status Consciousness Behaviour Look : : Conscious/Semiconscious/Unconscious : : Anxious/Depressed/Happy/Pleasant/Sad/Alert /Tired/Fearful Attitude Affect/Mood Speech : Cooperative/Withdrawn/Hostile : Appropriate to situation/Inappropriate to situation : Clear/Rapid/Slow/Slurring/Stammering/Relevant/ Irrelevant/Aphasia Orientation Vital Signs Temperature Pulse Respiration Blood pressure Height and Weight Height Weight A.

Hair : Evenly distributed/thick silky hair/alopecia/very thin hair/ Brittle hair/excessive oily/lice/nits/excessive hairness (Hirsutism) Texture Colour Grooming Subjective Symptoms C.B. Eyes Eye brows : Normal/dry : Black/brown/red/gray etc : Not groomed/well groomed : : Hair equally distributed/symmetrical/ asymmetrical/scanty etc Eye lashes Eye lids : Equally distributed/unequal : Skin intact/edema lesion/etropion (eversion)/entropion (inversion)/ Redness/lids closed symmetrically /asymmetrically/ incompletely/painful /ptosis (drooping of eyelids) Eye balls Pupils Colour Size Shape Reaction to light : Sunken/protruded : : Black/cloudiness : 3 ± 7 mm in diameter : Round/Oval/Irregular/pinpointed etc : PERLA->Pupils equally reacting to light and accommodation Corneal reflex Conjunctiva Sclera : Present/absent : Pale/normal/yellowish/purulent/conjunctivitis : White/jaundiced (yellow)/reddish etc 22 .

Lens Vision : Opaque/transparent : Client can see objects/myopia (short sight) hyperopia(Long sight) Extra ocular muscle test Subjective Symptoms : Normal/nystagmus/cross eye or squint : No complaints/pain/itching/increased or decreased production of tears etc D. Ear Position Cerumen Otorrhoea Subjective Symptoms Hearing : Normal/placed/low set ear : Absent/present : Absent/purulent/serous/blood : No complaints/otalgia/tinnitus/vertigo : : Normal voice tone audible/not audible Watch tick test (2cm ± 3cm distance : Able to hear ticking in both ears (weber negative)/not audible Turning fork test (weber test) : Sound is heard in both ears/sound is heard better in impaired ear Rinne test : Sound heard better in ear with out a problem AC>BC(+ve Rinne) BC=AC or BC>AC (-ve Rinne conductive hearing loss) Subjective Symptoms : Response to Normal voice tone 23 .

Mouth and Pharynx Outer lips : : : Pink/pale/ability to purse lips/asymmetry/symmetry/ soft/ moist/smooth texture/or scales Inner lips : Pink(freckled brown pigmentaion in dark skinned client)/moist/smooth/ soft/excessive dryness/pale/ leukoplakia(with patches)/ulcerations Teeth : Smooth/shiny tooth enamel/32 teeth(adult)/missing teeth/yellowish/ stains/ill fitting denture/brown/black white/dental caries/tooth ache/plague Gums : Pink/bleedingswelling/pus 24 . Nose External Nose : Symmetric & symmetric/discharge (present/ not present)/crusts Nasal Septum Patency of Nasal Cavity : Midline/deviated : Air moves freely as the client breaths through the nares/obstructed /nasal polyp Frontal & maxillary sinuses Smell Rhinorrhoea : Normal/painful/render/sinusitis : Normal/absent(anosmia) : Absent/watery/purulent/mucoid/epistaxis etc Subjective Symptoms F.E.

throat pain etc Voice Subjective Symptoms G. Neck Range of motion Thyroid gland Trachea Lymphnodes Jugular Veins : Clear/harsh/aphonia/dysphonia : : : Possible/painful/absent etc : Enlarged/not enlarged/removed etc : Midline/displaced etc : Palpable/not palpable/painful etc : Distended/not distended 25 .Tongue : Central position/deviated from center/pink colour/ moist/slightly/rough/thin/whitish coating/smooth red tongue/dry tongue/ lesions/ulcerations Movement : Moves freely/no tenderness/restricted mobility Palate : Light pink/smooth soft palate/lighter pink hard palate/discoloration Uvula : Positioned in midline of soft palate/deviation to one side from tumor or trauma/immobility Tonsils : Smooth/pink/pale/painful/enlarged/not enlarge Odour of mouth Pharynx : Foul smelling : Gag reflex(present/absent) sore throat/infections/ dysphagia. odynophagia.

Chest : Barrel chest/pigeon chest/funnel chest/transverse diameter is twice the anterior posterior diameter/ symmetrical/asymmetrical/flat/etc Expansion of the chest : Symmetry/asymmetry/delayed/shallow /etc Palpation Tactile fremitus : : Symmetry/asymmetry/decreased/ increased Thoracic excursion Auscultation Apical pulse Breath sounds : Resonance/hyper resonance : : «««. beats/mt : Normal vesicular sound/normal bronchial sound/ normal broncho vesicular sound/crackles/stridor/ rhonchi/ wheezing/pleural friction rub/bronchophony egophony/ whispered pectoriloguy Cough : Absent/if present(dry/whooping/ productive/ aggravating/factors etc Sputum : Absent/if present(bad odour/frothy/ mucoid/rusty/ sticky/purulent/green/yellow/blood stained etc Subjective Symptoms : No complaints/diaphoresis/breathless/ giddiness/palpitations/chest pain/shoulder pain/exercise intolerance etc 26 .H.

Abdomen Inspection Subjective Symptoms : No complaints/nausea/vomiting/heart burn/ abdominal pain/abdominal cramps/flatulence/ poly phagia etc. : Well distributed/scanty etc : : Skin rashes/scar/hermia/ascites/flat/abdominal pulsation seen/linea nigra/umbilicus clean/infected/ everted etc. Auscultation Abdominal girth Inguinal Lymphnodes Appetite : Bowel sounds heard/not heard : «««.Heart I. 27 . S2 heard/murmur/gallop sounds : : Symmetrical/asymmetrical : Colour/retracted/inverted/dimpling/erect etc Discharge Lesions/masses : Absent/milky/yellowish/purulent etc : Absent/ulcerations/nodes/swelling/moving/ painful/tender etc Auxiliary nodes Hair distribution : Not palpable/palpable/moving/painful etc. Palpation : Liver/(Palpable/not palpable)/spleen (palpable/not palpable)/tenderness/soft/masses etc Percussion : Presence of gas/presence of fluid/mass /detected/not detected.cms : Not enlarged/enlarged/movable/painful etc : Normal/anorexia/bulimia nervosa/anorexia nervous J. Breast & Axilla Symmetry Areola & nipple : S1.

planter (normal) (kneejerk) 28 . Skin Colour Texture Temperature Lesions Turgor Discoloration : : Fair/brown/dark in complexion : Dryness/wrinkling/excessive moisture/normal : Warm/cold and clammy/hot : Macules/papules/vesicles/wounds : Normal/decreased : Absent/yellowish/cyanosis/pallor/increased pigmentation L.. Oedema/Swelling Cyanosis Joints Deformity Lower extremities Symmetry Toe nails Range of motion Peripheral pulses : Absent/if present (specify area) : Absent/if present (specify area) : Stiffness/swelling/tenderness/crepitus etc/absent : Absent/if present (specify) : : Symmetry/asymmetry : Capillary refill «. rhythm. popilitial artery(normal rate.K. volume) if abnormal«««« Reflexes : Patellar. triceps.sec : Possible/not possible (specify) : Dorsalis pedis. Upper extremities Symmetry Range of motion Peripheral pulses : : Symmetrical/asymmetrical : Possible/if impossible (specify) : Brachial. rhythm. radial pulses (normal rate.. posterior tibial artery. ankle jerk. brachio radialis normal if abnormal.. volume) Reflexes : Biceps.

Genitals and Rectum 29 .if abnormal Oedema/ Swelling Cyanosis Joints Deformity : Absent/ if present (specify area) : Absent/ if present (specify area) : Stiffness/ Swelling/ Tenderness/ Crepitus/ etc. adduction. M. extension.. external and internal rotation etc.seconds N. Nails Shape : Convex curve (schamroth¶s window test)/ spoon shape (Koilonychia)/ Clubbing Texture : Smooth/excessive thickness/ excessive thinness/ presence of grooves or furrows/ Beau¶s line (Transverse white lines or grooves on nail may result from severe injury or illness Nail bed color : Pink/ cyanosed/ pale etc Tissues surrounding nails : Intact epidermis/ hang nails/ paronychia (inflammation of the tissues surrounding a nail) Capillary refill : (Blanch test) ««««. abduction. : Talipes equino varus/ Talipes equino valfum/ bow legs/etc/ absent Subjective symptoms : No complaints/pain while walking or doing daily activities/musclecramps/myalgia/problems with flexion.

and support networks etc. in what way it provides a sense of purpose etc. illness. finances. Emotional Health It includes the mental health status stress and coping styles of the individual.Hemorrhoids : Present/ not present Vaginal Discharge : Present/ not present Enlargement of prostate gland : Enlarged/ not enlarged Testis : Descended into scrotum/ undescended testis Labia majora & Labia minora : Labia minora is covered by labia majora/ Labia minora is not covered by labia majora/ ambuigous/ umambiguous Psychological Assessment Client¶s Perception It includes the perception of the patient about the referral service assessment. Social Health It includes accommodation. drugs etc. weight. traditional beliefs. genogram. tobacco. employment status. values of the society. diurinal variations. previous history. sleep pattern. Spiritual Health: It includes the patient¶s belief about the religion. ethnic background. relationship. Physical Health It includes the assessment general health. alcohol. 30 . the importance of religion. the gain achieved by the patient from the meeting with the nurse. appetite. culture.

Jumping to conclusions or focusing in the wrong direction CUES : The subjective and objective data identified by nurse act as cues.Intellectual Health: It comprises cognitive functioning.  Values and beliefs. hobbies. etc. patient states ³I just started taking penicillin for a tooth abscess´ Objective data. Subjective data.. Missing pertinent information 2. INFERENCE:The cues help to make judgment called inference. Misunderstanding Situation 3.  Expertise in clinical practice. Identifying of correct inferences it will influenced by nurse¶s  Observational skills.g. interests. the patient is having allergic reaction to penicillin. Cues.  Nursing knowledge. fine rash over trunk. hallucinations. the above objective and subjective data¶s act as cues. E. Validating data helps to avoid 1. 31 . Inference. Validating Data It is a act of making sure that to know which data are actually fact and which data are questionable. delusions. concentrations.

If data are questionable use the following techniques. When the information is critical. peer group) j Always double check data that are extremely abnormal j Compare your subjective & objective data 32 . Journals. j Recheck your own data j Look for temporary factors that may alter the accuracy of your data j Ask someone else ( experts.Methods for the validation of cues and inferences DATA VALIDATION Identification of Cues Make Inferences About Cues Validate Cues and inferences Compare Cues to Knowledge Base of Normal Function Refer to Textbooks. you verified it directly observing and interviewing the patients. j Keep in mind that data that someone else observes to be factual may or may not be true. Research Reports Check Consistency of Cues Clarify Client¶s Statements Seek Consensus With Peers and Colleagues About Inferences Guidelines for Validating data j Be aware that data that can be measured with an accurate scale of measurement can be accepted as factual.

Organization of Assessment Data According to Functional Health Patterns 1. and actual and potential health problems. Nutritional-metabolic pattern. Activity-exercise pattern. 33 . Physiological needs. Self-perception-self-concept pattern. 3. 7. Safety and security needs. After validating the patients data the nurse has to organize them into categories of information that will help to identify patients strengths. 2. 4. Cognitive-perceptual pattern. Self-actualization needs. Functional Health Patterns 3. 5. 5. 4.Organizing Data Clustering the data into groups of information that will help the nurse to identify patterns of health or disease. Data can be clustered according to 1. Body System Organization Assessment Data According to Human Needs (Maslow) 1. 3. Love and belonging needs. Self-esteem needs. Health-perception-health-management pattern. 6. Elimination pattern. Human needs 2. Role-relationship pattern. 8. Sleep-rest pattern. 2.

7. she can now more readily identify key missing pieces. Integumentary system. 6. This can be done by using puzzle analogy. Respiratory system. Sexuality-reproductive pattern. Nurse can get some initial impressions about the presents of certain patterns when cluster the data. Coping-stress-tolerance pattern. 5. 34 . This initial impressions are often helpful in identifying gaps in the data collection. and gathering additional data to fill in the gap to describe more clearly what the data mean. 11. 3. 8. Gastrointestinal system. 2. The nurse can examine many pieces of information and put some of the pieces of the picture together. Musculoskeletal system. Because the nurses have quite a few of the pieces together. Value-belief pattern. Genitourinary system. Cardiovascular system. 10. Cluster together a brief client profile. 4.9. Once we clustered the data into groups of related information we can able to identify pattern and filling in the gaps of missing data. Nervous system. Clustering Data According to Body Systems 1. Identifying Patterns and Filling in the Gap Making an initial impression about patterns of information.

Label the problems correctly. Written Communication Verbal communication of significant findings (E.The nurse should be comprehensive in this process. Verbal Communication 2. Identify all the problems. Identify appropriate individualized interventions.g. Identify interventions that are not likely to work. Use ink and write or pint legibly. By this the nurse is Less likely to Miss problems.. More likely to Identify client strengths. Communicating Data Reporting or recording significant data to expedite treatment and completing the database. Follow an organized method of recording data. pain. Abnormal vital signs. 2. problems with breathing or circulation) should be given priority over completing nursing database records. The data can be communicated through 1. 35 . 3. Identify problems that are not there. Document the name of any person contributing to the history other than the patient. Guideline for recording the data: 1. Miss label problems. Followed precisely hospital policies and procedures for recording the data. 4.

Chart the most critical data first. 6. the data will be readily available. Be clear when you record what you observe. medications. 7. Vital signs. Chart whom you notified if you have reported significant data.g. 8.. (E.5. allergies) so that if the nurse leave the unit for some reason. Write patient¶s statements using the patient¶s own words. 36 .

organized. Ethical norms. (ii) Use analytical models and problem solving tools) Attitude Perseverance Fairness Integrity Confidence Creativity 37 .Critical Thinking in Assessment Process The nurse must apply the principles of critical thinking when performing client¶s assessment. Normal growth and development. Observation of assessment techniques. Knowledge on physical and social sciences. Health promotion. Standards of measurement (i) Use evidence based assessment techniques and instruments to collect data. Nursing Assessment Standards Standards of nursing practice. Normal assessment findings. cognitive process used to carefully examine the clinical decision making of assessment. Validation of assessment findings. Technical skill. Knowledge Underlying the disease process. Normal psychology.         Experience Previous client care experience. Assessment skills. Critical thinking is the active.

Assessment and clinical nursing judgment Assessment of client¶s health status y Client. health care resources comprise database y Nurse clarifies inconsistent or unclear information y Critical thinking guides and directs line of questioning and examination to reveal detailed and relevant database Validate data with other sources Reassess Is additional data needed? Yes No Interpret and analyze meaning of data Cluster data y Group signs and symptoms y Classify and organize Begin formulation of nursing diagnosis 38 . family.

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