PATIENT

ASSESSMENT
Ririn Muthia Zukhra

RMZ/Inggris3/2022
INTRODUCTION
❑ The professional nurse plays a vital role in
the assessment of patient problems.
❑ Educational preparation and the clinical
setting in part determine the extent to
which the nurse participates in the
assessment process
 3

INTRODUCTION
Assessment is the first step to determine health
status. It is the gathering of information to have all
the “necessary puzzle pieces” to make a clear
picture of the person’s the health status.

The entire plan of care is basedon the data you

collect during this phase and make every effort to
ensure that your information is correct, complete
and organized in a way that you will begin to get a
sense of patterns of health or illness.
DEFINITION OF ASSESSMENT 4

According to Carpenito:
Assessment is the deliberate and systematic
collection of data to determine a client’s current
and past health status functional status and to
determine the client’s present and coping pattens.

Atkinson & Murray (1991):

Assessment is a part of each activity the nurse does
for and with the patient
PURPOSES OF ASSESSMENT
a. To gather information regarding client’s
health
b. To determine client’s normal function
c. To organize the collected information
d. To confirm hypothesis growing out of the
nurses’s interview
e. To enhance investigation of nursing problems
f. To framenursing diagnosis
g. It increases greater managing skill of handling
patient’s problem
h. To identify the health problems
i. To identify client’s strengths
j. To identify need for health teaching
 6

TYPES OF ASSESSMENT

INITIAL ASSESSMENT FOCUS ASSESSMENT EMERGENCY TIME-LAPSED

ASSESSMENT​ ASSESSMENT
 7

INITIAL ASSESSMENT
It is performed within specified time after admission to a health care
agency.

Purpose: to establish a complete data base for problem identification,

reference, and future comparison

Ex: nursing admission assessment

 FOCUS OR ONGOING
8

ASSESSMENT
• Ongoing process integrated with nursing care

• Purpose: to determine the status of a specific problem identified in

an earlier assessment and to identify new oroverlooked problem

• Ex: hourly assessment of client’s fluid intake and output chart

 EMERGENCY ASSESSMENT
9

• During any ohysiologic or psychologic crisis of the client.

• Purpose: to identify life-threatening problems.

• Ex: a) Rapid assessment of person’s airway, breathing, status and

circulation during a cardiac arrest
b) Assessment of suicidal tendencies or potential for violence.
 TIME-LAPSED ASSESSMENT
10

• Several months afterinitial assessment

• Purpose: to comparethe client’s current status to baseline data

previously obtained.

• Ex: reassessmentof a client’sfunctional health patterns in a home

care
Presentation title 11

METHODS OF ASSESSMENT

INTERVIEWING OBSERVING EXAMINING

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INTERVIEWING
An interview is a planned communication or a conversation with a
purpose.

Ex: history taking

There are two approaches for interviewing:

1. Directive approach
2. Non directive approach
 13

OBSERVING
An observation is a conscious, deliberate skill that is developed only
through and with an organized approach

Ex: client data observed through four senses that is through vision, smell,
hearing, and touch.
 14

EXAMINING
The physical examination is a systematic data collection method that uses
observational skills to detect health problems.

To conduct the examination, the nurse uses four techniques. There are :
1) Inspection
2) Auscultation
3) Palpation
4) Percussion
“ PHYSICAL ASSESSMENT
” 15

Head to Toe Assessment

Body Systems Assessment

 16

TIMELINE

NOV 20XX JAN 20XX MAR 20XX

Disseminate Coordinate e- Foster holistically

standardized business applications superior methodologies
metrics
 17

AREAS OF FOCUS
B2B MARKET SCENARIOS CLOUD-BASED OPPORTUNITIES

• Develop winning strategies to keep • Iterative approaches to corporate strategy

ahead of the competition • Establish a management framework
• Capitalize on low-hanging fruit to from the inside
identify a ballpark value
• Visualize customer directed convergence
Presentation title 18

SUMMARY
At Contoso, we believe in giving 110%. By using our next-generation
data architecture, we help organizations virtually manage agile
workflows. We thrive because of our market knowledge and great team
behind our product. As our CEO says, "Efficiencies will come from
proactively transforming how we do business."
THANK YOU
Mirjam Nilsson
mirjam@contoso.com
www.contoso.com
Presentation title 20

HOW WE GET THERE

NICHE MARKETS

• Pursue scalable customer

service through sustainable
strategies
• Engage top-line web
services with cutting-edge
deliverables
 INSPECTION
21

• Close and careful visualization of the person as a whole and of each

body system

• Ensure goog lighting. Perform at every encounter with your client

 PALPATION
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• Temperature, texture, moisture

• Organ size & location
• Rigidity or spacity
• Crepitation& vibration
• Position & size
• Presence of lumps or masses
• Tenderness, or pain
 PERCUSSION
23

Assess underlying
structures for
location, size,
density of
underlying tissue
 AUSCULTATION
24

listening to sounds produced

bu the body

Instrument: stethoscope (to

skin)
Diaphragm: high pitched
sounds heart, lungs, abdomens

Bell: low pitched sound: blood

vessels
Presentation title 25

ASSESSMENT PROCESS

COLLECT DATA ORGANIZE VALIDATE DATA DOCUMENTING

DATA DATA
 26

ASSESSMENT PROCESS
The assessment process involves four closely related activities:
1. Collecting data: Process of gathering information

Types • subjective
of Data • objective
 27

TYPES OF DATA
When performing an assessment the nurse gathers subjective and
objective data

Subjective data : the verbal statements provided by the patient.

Statements about nausea and descriptions of pain and fatigue are
examples of subjective data.
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TYPES OF DATA
Objective data (sign or over data):
Are detectable by an observer or can be measured or tested against an
accepted standard. They can be seen, heard, felt, or smelt, and they are
obtained byobservation or physical examination.

For example: discoloration of the skin

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SOURCES OF DATA
Data can be obtained from primary or secondary source.

The primary source of data is the patient. In most instances the patient is
considered to be the most accurate reporter. The alert and oriented
patient can provide information about past illness and surgeries and
present sign, symptoms, and lifestyle.

When the patient is unable to supply information because of

deterioration of mental status, age, or seriousness of illness, secondary
sources are used.
Presentation title 30

the secondary sources of data include family members, significant

others, medical records, diagnostic procedures

members of the patient’s support system may be able to furnish

information about the patient’s past health status, current illness,
allergies, and current medications.

Other health team professionals are also helpful secondary sources

(physician, other nurses)
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ORGANIZING DATA
Cluster the data into groups of information that help you identify
pattern of health or illnesses.

The nurse uses a written or computerized format that organizes the

assessment data systematically. The format may be modified according to
the client’s physical status
Presentation title 32

VALIDATING DATA
• The information gathered during the assessment phase must be
complete, factual, and accurate because the nursing diagnosis and
interventions are based on this information.

• Validation is the act of “double-checking” or verifying dta to

confirmthat it is accurateand factual
Presentation title 33

DOCUMENTING DATA
to complete the assessment phase, the nurse records client’s data.

Accurate documentation is essential and should include all data collected

about the client’shealth status. Data are recorded in a factual manner and
not interpreted by the nurse.

Eg: the nurse record the client’s breakfast intake as “coffee 240 ml, juice 120
ml, 1 egg”. Rather than as ”appetite good”
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