Chapter 16: Nursing Assessment

The Nursing process is a critical thinking five-step process that professional nurses use to apply the best
available evidence to caregiving and promoting human functions and responses to health and illness
(ANA, 2010). It is the fundamental blueprint for how to care for patients. A patient-centered care
approach is holistic and essential when applying the nursing process. As a nurse you learn to make
clinical judgments from assessment data to identify a patient's level of wellness and desire for health
promotion or to identify existing health problems. The nursing process is a form of scientific reasoning.

A Critical Thinking Approach To Assessment

Assessment is the deliberate and systematic collection of information about a patient to determine the
patient's current and past health and functional status and his or her present and past coping patterns
(Carpenito- Moyet, 2013). Nursing assessment includes two steps:

1. Collection of information from a primary source ( a patient ) and secondary sources ( e.g.,
family or friends, health professionals, and the medical record )
2. The interpretation and validation of data to ensure a complete database

Developing the Nurse-Patient Relationship for Data Collection

An assessment is necessary for you to gather information to make accurate judgments about a patient's
current condition. Your information cones from:

 The patient through interview, observation, and physical examination.

 Family members or significant others' reports and response to interviews.
 Other members of the health care team.
 Medical record information (e.g., patient history, laboratory work, x-ray film results,
multidisciplinary consultations).
 Scientific and medical literature (evidence about disease conditions, assessment techniques, and
standards).

Patricia Benner (1984) described in her early research the importance of a healing relationship
established between nurse and patient. This relationship process mobilize hope for a patient and nurses;
allows for an acceptable interpretation and understanding of a patient's illness, pain, fear, and anxiety;
and helps a patient use support from health care providers (Benner,1984).

Types of Assessment

Remember that assessment is all about accurate and thorough data collection. You will learn to conduct
different types of assessments: the patient-centered interview during a nursing health history, a physical
examination, and the periodic assessment you make during rounding or administrating care. When you
begin assessment, think critically about what to assess for that specific situation. As you are forming your
relationship and connecting with a patient, the patient will begin to share information.
A cue is information that you obtain through use of the senses. An inference is your judgment or
interpretation of these cues.When you conduct a more comprehensive patient history detailed
assessment of a patient's physical, physical, psychological, social, cultural, and spiritual needs), there are
two approaches to this assessment.

The second approach for conducting a comprehensive assessment is problem oriented. You focus on a
patient's presenting situation and begin with problematic areas such as incisional pain or limited
understand of postoperative recovery.

Whatever approach you use to collect data, you cluster cues, make inferences, and identify emerging
patterns and potential problem areas. Knowing how to probe and frame questions is a skill that grows
with experience. You learn to decide which questions are relevant to a situation and attend to accurate
data interpretation on the basis of inferences and experience.

Types of Data

There are two primary sources of data: subjective and objectives. Subjective data are your patient's
verbal descriptions of their health problems. Objectives data are observations or measurements of a
patient's health status.

Source of Data

Patient. A patient is usually your best source of information. Patients who are conscious, alert, and
able to answer questions without cognitive impairment provide the most accurate information.

Family and Significant others.Family and Significant others are primary sources of information for
infants or children, critically I'll adults, and patients who are mentally handicapped or have cognitive
impairment.

Health Care Team. You frequently communicate with other health care team members to assess
patients. In the acute care setting the change-of-shift report, bedside rounds, and patient hand-off are
ways that nurse from one shift communicate information to nurses on the next shift.

Medical Records. The medical record is a source for a patient's medical history, laboratory and
diagnostic test results, current physical findings, and the primary health care provider's treatment plan.

Other Records and the Scientific Literature. Educational, military, and employment records often
contain significant health care information. Reviewing recent nutsing, medical, and pharmacological
literature about a patient's illness completes a patient's assessment database.

Nurse's Experience. Your experiences in caring for patients are a source of data. Through clinical
experience you observe other patients' behaviors and physical signs and symptoms; track trends and
recognize clinical changes; and learn the types of questions to ask, choosing the questions that will give
the most useful information.

The Patient-Centered Interview

When a patient is admitted to a health care agency or when it is necessary to gather detailed
information about a patient, you will collect an assessment using interview and observation skills. One
type of patient-centered interview is motivation interviewing.

Effective communication with patients during an assessment interview requires the following
communication skills (Ball et al., 2015):

 Courtesy: Greet patients by the name by which they prefer to be addressed.

 Comfort: If a patient is having symptoms such as pain, nausea or fatigue, it is difficult for you to
gather a through and accurate history.
 Connection: It is so important to make a good first impression. If you begin collecting a history by
staring at a computer screen to fill in required data fields or taking on a cell phone , patients will
perceive you as uncaring or uninterested in hearing their stories.
 Confirmation: At the end of interview, ask the patient to summarize the discussion so there are
no uncertainties. Be open to further clarification or discussion.

Interview Preparation

Before you begin an interview, be prepared. Review a patient's medical record when information is
available. If your interview is performed at patient admission, there may be little information in the
medical record except for an admitting diagnosis.

Phase of an Interview

An interview is an approach for gathering subjective and objective data from a patient through an
organized conversation. An initial interview involves collecting a nursing health history and gathering
information about a patient's condition.

Orientation and Setting an Agenda. Begin an interview by introducing yourself and your position and
explaining the purpose of the interview. Explain why you are collecting data and assure patients that all
of the information will be confidential.

Working Phase-Collecting Assessment or Nursing Health History. Start an assessment or a nursing

health history with open-ended questions that allow patient to describe more clearly their concerns and
problems.

Terminating an Interview. Terminating of an interview requires skill. You summarize your discussion
with a patient and check for accuracy of the information collected.

Interview Techniques

How you conduct an interview is just as important as the questions you ask. During an interview you are
responsible for directing the flow of the discussion so patients have the opportunity to freely contribute
stories about their health problems to enable you to get as much detailed information as possible.
 Observation. Observation is powerful. Observe a patient's non-verbal communication such as use of
eye contact, body language, or tone of voice.

Open-Ended Questions. In a patient-centered interview you try to find out, in the patient's own
words, his or her health goals and any concerns or problems that exist and their probable cause. An
open-ended questions gives a patient discretion about the extent of his or her answer.

Learning Question. These questions are the most risky because of possibly limited the information
provided to what a patient thinks you want to know.

Back Channeling. Reinforce your interest in what a patient has to say through the use of good eye
contact and listening skills. Also use back channeling, which includes active listening promots such as "all
right", "go on", or "uh-huh".

Probing. As a patient tells his or her story, encourage a full description without trying to control the
direction the story takes. If a patient becomes fatigued or uncomfortable, know that it is time to
postpone an interview.

Direct Closed- ended Questions. As you learn information from a patient, you will ask direct questions
to seek specific information. This problem-seeking technique gives details to identify a patient's problem
accurately.

Nursing Health History

You gather a nursing health history during an initial or early contact with a patient. The history is a key
component of a comprehensive assessment. Most health history forms (manual and electronic) are
structured. However, on the basis of information you gain as you conduct the patient-centered interview,
you learn which components of the history to explore fully and which require less detail.

Component of the Nursing Health History

Most health histories contain the same components. Do not let a history form shape your assessment
entirely. Decide what information you need on the basis of your patient's needs, responses to your
questions, and changing status during the interview.

Biographical Information. Biographical information is factual demographic data that include a patient's
age, address, occupation, and working status; source of health care; and types of insurance. The staff in
an admitting office usually collects this information.

Chief Concern or Reason for Seeking Health Care. This is the information you gather when you initially
set an agenda during a patient-centered interview. You learn a patient's chief concerns or problems.
Compare what you learn from the patient with the "chief complaint", which is often typed on the
patient's admission sheet.

Patient Expectations. It is important to assess a patient's expectations of health care providers ( e.g.,
being diagnosed correctly, receiving comfort measures, or being treated successfully for a disease).
Patient satisfaction, a standard measure of quality for all hospitals throughout the country, can be
perceived by patient's as poor of their expectations are unmet.

Present Illness or Health Concerns. If a patient presents with an illness, collect essential and relevant
data about the symptoms and their effects on the patient's health. Apply critical thinking intellectual
standards and use the acronym (PQRST) to guide an assessment:

 P-provokes (e.g., precipitation and relieving factors): What causes symptom? What makes it
better or worse? Are there activities (e.g., exercise) that affect it?
 Q-quality: what does the symptoms feel like? If patient cannot describe, offer probes such as "Is
it sharp? Dull? Burning?"
 R-radiate: where is the symptom located? Is it in one place? Does it go anywhere else? Have
patient be as precise as possible.
 S-severity: ask a patient to rate the severity of a symptom on a scale of 0 to 10. This gives you a
baseline with which to compare in follow-up assessment.
 T-time: assessment onset and duration of symptom. When did it start? Does it come and go? If
so, how often and for how long? What time of day or day of the week?

Health History. A health provides a holistic view of a patient's health care experiences and current health
habits. Assess whether a patient has ever been hospitalized or injured or has had surgery. Include a
complete medication history (including herbal and over-the-counter OTG drugs).

Family History. The family history includes data about immediate and blood relatives. Your objective is to
determine whether a patient is at risk for illnesses of a genetic or familial nature and to identify areas of
health promotion and illness prevention.

Psychological History. A psychosocial history provides information about a patient's support system,
which often includes a spouse or partner, children, other family members, and close friend. The history
also includes information about ways that a patient and family typically cope with stress.

Spiritual Health. Life experience and event shape a person's spirituality. The spiritual dimensions
represents the totality of one's being and is difficult to assess quickly. Review with patients their beliefs
about life, their source for guidance in acting on beliefs, and the relationship they have with family in
exercising their faith.

Review of Systems. The review of system (ROS) is a systematic approach for collecting subjective
information from patients about the presence or absence of health-care Ted issues in each body system
(Ball et al., 2015).

Observation of Patient Behavior

Throughout a patient-centered interview and physical examination it is important to closely observe a

patient's verbal and nonverbal behaviors. The information adds depth to your objective database. An
important aspect of observation includes a patient's level of function: the physical, developmental,
psychological, and social aspects of everyday living.
Diagnostic and Laboratory Data

The results of diagnostic and Laboratory test provide further explanation of alternations or problems
identified during the health history and physical examination.

Interpreting and Validating Assessment Data

Assessment involves the continuous interpretation of information. This is a critical thinking aspect of
assessment. The successful ongoing interpretation and validation of assessment data ensurs that you
have collected a complete database.

Interpretation. When critically interpretation assessment information, you determine the presence of
abnormal findings, recogniza that further observations are needed to clarify information, and begin to
identify a patient's health problems.

Data Validation. Before you complete data interpretation, validate the information you have collected
to avoid making incorrect inferences. Validation of assessment data is the comparison of data with
another source to determine data accuracy.

Data Documentation

Record the result of the nursing health history and physical examination in a clear, concise manner using
appropriate terminology. This information becomes the baseline to identify patient health problems,
plan, and implement care, and evaluate a patient's response to interventions.a

Concept Mapping

Most patients for whom you care will present with more than one health problem. A concept map is a
visual representation that allows you to graphically show the connections among a patient's many health
problems. The concept map is a strategy that develops critical thinking skills by helping a learner
understand the relationships that exist among patient problems.

Chapter 17: Nursing Diagnosis

During the nursing assessment process you gather information about a patient from a variety of source.
As you collect and analyze the data you begin to recognize cues that form patterns of data that indicate
either a patient's level of wellness and desire for health promotion or his or her existing health
problems. When physicians and certified advance practice nurses identify common medical diagnoses
such as diabetes mellitus or osteoarthritis, they all know the meaning of the diagnoses and the standard
approaches for treatment. A medical diagnosis is the identification of a disease condition based on a
specific evaluation of physical signs and symptoms, a patient's medical diagnosis stays constant as a
condition remains. A nursing diagnosis is a clinical judgement concerning a human response to health
conditions/life processes, or vulnerability for that response by an individual, family, or community that a
nurse is licensed and competent to treat ( Herdman and Kamitsuru, 2014). A collaborative problem is an
actual or potential physiological complication that nurses monitor to detect the onset of changes in a
patient's health status ( Carpenito- Moyet, 2013).

History of Nursing Diagnosis

Nursing diagnosis was first introduced in the nursing literature in 1950 ( McFarland and McFarlane,
1989). Fry ( 1953) proposed the formulation of nursing diagnoses and an individualized nursing care plan
to better define nursing practice and science. Nurses make diagnostic conclusions using nursing
diagnosis to form clinical decision necessary for safe and effective nursing practice. The use of standard
formal nursing diagnostic statements serves several purposes in nursing practice:

 Provides a precise definition of a patient's responses to health problems that gives nurses and
other members of the health care team a common language for understanding a patient's needs
 Allows nurses to communicate (e.g., written and electronic) what they do among themselves
with other health care professionals and the public
 Distinguishes the nurse's role from that of other health care providers
 Helps nurses focus on the scope of nursing practice
 Fosters the development of nursing knowledge
 Promotes creation of practice guidelines that reflect the essence and science of nursing

Types of Nursing Diagnoses

NANDA-1 nursing diagnoses include three types: problem-focused, risk, and health promotion (Herdman
and Kamitsuru, 2014). A problem-focused nursing describes a clinical judgement concerning an
undesirable human response to a health condition/life process that exists in an individual, family, or
community. A risk nursing diagnosis is a clinical judgement concerning the vulnerability of an individual,
family, group, or community for developing an undesirable human response to health conditions/life
processes ( Herdman and Kamitsuru, 2014). These diagnoses do not have defining characteristic or
related factors. A health promotion nursing diagnosis is a clinical judgement concerning a patient's
motivation and desire to increase well-being and actualize human health potential ( Herdman and
Kamitsuru, 2014).

Critical Thinking and The Nursing Diagnostic Process

The diagnostic process requires you to use critical thinking. You will learn to apply your knowledge,
experience, critical thinking attitudes and intellectual standards when you collect and analyze
assessment data to identify nursing diagnoses. In the practice of nursing it is important for you to know
the nursing diagnostic labels, their definitions, the defining characteristic or risk factors for making
diagnoses, related factors pertinent to the diagnoses, and the intervention suited for treating the
diagnoses ( Herdman and Kamitsuru, 2014). The diagnostic reasoning process involves using the
assessment data you gather about a patient to logically explain a clinical judgement.

Data Clustering
Analysis and interpretation of assessment data begin by organizing all of a patient's data into meaningful
and usable data clusters. A data cluster is a set of cues, the signs or symptoms gathered during
assessment. Each cue is an objective or subjective sign, symptom, or risk factor that, when analyzed with
other cues, begins to lead to diagnostic conclusions.

Data Interpretation

While analyzing clusters of defining characteristics or risk factors, you consider a patient's responses to
health condition. Your interpretation of the information allows you to select among various diagnoses
that may appy to your patient.To be more accurate,review all characteristics or risk factors, eliminate
irrelevant ones, and confirm the relevant ones.It is critical to select the correct diagnostic label for a
patient's need. Usually from assessment to diagnosis you move from general information to
specific.Often a patient has defining characteristics or risk factors that apply to more than one diagnosis.
While focusing on patterns of defining characteristics, compare a patient's pattern of data with
information that is consistent with normal, healthy patterns. Use accepted norms as the basis for
comparison and judgment such as laboratory and diagnostic test values, prefesional standards and
nornal anatomical or physiological limits already established.Nursing diagnoses provide the basis for
selection of nirsing intervrntions to achieve outcomes for which ypu, as a nurse, are accountable. A
nursing diagnosis focuses on a patient's actual or potential response to a health condition rather than on
thr physiological event, complucation, or disease.

Formulating a Nursing Diagnostic Statement

After clustering assessment data and intrepreting the meaning, your aim is to select the correct nursing
diagnostic statement. The diagnostic label is the name of the nursing diagnosis as approved by NANDA-I.
It describes the essence of a patient's response to health conditions in as few worda as possible. The
definition describes the cjaracteristics of the human response identified and helps to select the correct
diagnosis.

A complete doagnostic statement will also include a rated factor ( appropriate for problem-based and
some health promotion diagnoses). When communicating a nursing diagnosis, through either discusuons
with health care colleagues or documentation of your care, use the language adopted within an agency.

To write a three-part nursing diagnosis, the acronym PES, which stands for problem, etiology, and
symptoms,is helpful.

P ( problem)- NANDA-I label-example: Impaired Physical Mobility

E ( etiology or related factors) example: incisional pain

S( symptoms or defining characteristics) Briefly lists defining characteristic that show evidence of the
health problem.

Cultural Relevance of Nursing Diagnoses

When you select nursing diagnoses,consider your patients' cultural diversity, including values,beliefs,
health practices, ethnicity, and gender.This also includes knowing the cultural differences that affect how
patients define health and illness and their requests or choice for treatment. It is important to consider
your patient's culture and your own cultural competence to accurately identify a patient's health care
problems. The definition for the diagnosis is a patient reporting a habit of life that is characterized by a
low physical activity level. Consider asking these questions to make culturally competent nursing
diagnoses:

How has this health problem affected you and your family?

What do you believe will help or fix the problem?

What worries you the most about this problem?

What do you expect from us, your nurses, to help maintain some of ypur values or practices for staying
healthy?

Which cultural practices do you observe to keep yourself and your family well?

When you ask questions such as these, you use a patient- centered aprroach that allows you to see a
patient's health situation through his or her eyes.

Concept Mapping Nursing Diagnoses

In chapter 16 you learned how concept mapping offers a graphic look at the connections among
patient's multiple health problems. A concept map helps you critically think abour a patients' diagnoses.
Concept mapping helps you organize and link data about a patient's multiple diagnoses in a logical way.
It graphically represents the connections amimong concepts that relate to a central subject. Concept
mapping organizes and link information to allow you to see a dynamic holism and cmplexity of
individualized patient care. The advantage of a concept map is its central focus on a patient rather than
on a disease or health alteration.

Sources of Diagnostic Errors

Errors occur in the nursing diagnostic process during data collection, clustering, and interpretation and in
making a nursing diagnostic statement. Accuracy in the selection of nursing diagnoses requires
methodical critical thinking.

Errors in Data Collection

During assessment be knowledgeable, thorough, and skillful. Avoid inaccurate or missing data amd
collect data in an organized way. Application of intellectual standarda for critical thinking will help you
gather the comprehensive information you need.

Errors in Intrepretation and Analysis of Data

Following data collection review your database to decide if it is accurate and complete. Validate that
measurable,objective physical finding support subjective data.

Errors in Data Clistering

Errors occurs when you cluster data prematurely, incorrectly, or not at all. Premature clustering occurs
when you make a nursing diagnosis before grouping all data. Always identify a nursing diagnosis from the
data, not the reverse. An incorrect nursing diagnosis affects quality of patient care.

Errors in the Diagnostic Statement

Clinical reasoning leads to a higher-quality level of nursing diagnosis, which eventually leads to etiology-
specific interventions and enchanced patient outcomes. Be sure that the etiology portion of the
diagnostic statement is within the scope of nursing to diagnose and treat. Additional guidelines to
reduce errors in the diagnostic statement follow.

1. Identify a patient's response, not the medical diagnosis (Carpenito-Moyet, 2013). Because a medical
diagnosis requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis.
Change the diagnosis Acute pain related to colectomy to acute pain related to trauma of a surgical
incision.
2. Identify a NANDA-1 diagnostic statement rather that the symptom. Identify nursing diagnoses from a
cluster of defining characteristics and not just a single symptom. One defining characteristic is
insufficient for problem identification.
3. Identify a treatable related factor or risk factor rather than a clinical sign or chronic problem that is
not treatable through nursing intervention.
4. Identify a problem caused by the treatment or diagnostic study rather than the treatment or study
itself. Patients experience many responses to diagnostic test and medical treatments.
5. Identify a patient response to the equipment rather than the equipment itself. Patient are often
unfamiliar with medical technology and it use.
6. Identify a patient's problems rather than your problems with nursing care. Nursing diagnoses are
always patient centered and form the basis for goal-directed care.
7. Identify a patient problem rather than a nursing intervention. You plan nursing interventions after
identifying a nursing diagnosis. More appropriate interventions are selected rather than a single
intervention that alone will not solve the problem.
8. Identify a patient problem rather than the goal of care. You establish goals during the planning step
of the nursing process. Goals based on accurate identification of a patient's problems serve as a basis
to determine problem resolution.
9. Make professional rather than prejudicial judgements. Base nursing diagnoses on subjective and
objective patient data and do not include your personal beliefs and values.
10. Avoid legally inadvisable statements ( Carpenito-Moyet, 2013). Statements that imply blame,
negligence, or malpractice have the potential to result in a lawsuit.
11. Identify the problem and etiology to avoid a circular statement. Circular statement are vague and
give no direction to nursing care.
12. Identify only one patient problem in the diagnostic statement. Every problem has different specific
expected outcomes. Confusion during the planning step occurs when you include multiple problems
in a nursing diagnosis.

Documentation and Informatics

Once you identify a patient's nursing diagnoses, enter them either on the written plan of care or in the
electronic health information record (EHR) of the agency. State-of-the-art EHR's contain nursing
diagnoses with NANDA-I approved diagnoses, interventions and outcomes, related or risk factors, and
defining characteristic. These are agencies with EHR's that do not use NANDA-I terminology. This makes
entry of NANDA-I diagnoses more tedious. However it is important to know why to use NANDA-I
terminology in a medical record entry ( Herdman and Kamitsuru, 2014):

 NANDA-I diagnoses have a broad literature base, with many diagnoses being evidence based.
Patient safety requires accurate documentation of health problems.
 NANDA-I classifications are the most comprehensive.
 NANDA-I diagnoses are under continual refinement and development by professional nurses.

Nursing diagnoses: Application to Care Planning

Nursing diagnosis is a universal means for communication among professional nurses and across other
health care disciplines. Diagnoses direct the planning process and the selection of nursing interventions
to achieve desired outcomes for patients. By making accurate nursing diagnoses, your subsequent care
plan communicates a patient's health care problems to other professionals and ensures that you select
relevant and appropriate nursing interventions.