Role of the Nurse and

Assessment
 Nursing Assessment versus
Medical Assessment
• Assessment is not unique to nursing. It is
also an integral part of medical practice.
• Medical practice - The goal is to
diagnose and treat disease.
• Nursing practice The goal is to diagnose
and treat human responses to actual or
potential health problems.
Nursing assessment
• focuses not only on physiological and
psychological responses but also on the
psychosocial, cultural, developmental, and
spiritual dimensions…
• Medical and nursing assessments should
complement, not contradict, each other in
promoting the patient’s health and
wellness. .
Levels of Preventive
Healthcare
Levels of Preventive
Healthcare
 Levels of Preventive
Healthcare
1. Primary preventive care
• focuses on health promotion and guards
against health problems.
• The focus is not only wellness but also to
minimize the risk of health problems.
• Examples include health fairs,
immunizations, and nutritional
instructions.
 Levels of Preventive
Healthcare
2. Secondary preventive care
• focuses on early detection, prompt
intervention, and health maintenance for
patients with health problems.
• It addresses acute health problems seen
with inpatient hospitalization.
 Levels of Preventive
Healthcare
3. Tertiary preventive care
•deals with rehabilitative or extended care.
Although the patient’s health status is
generally more stable than in secondary care,
patients usually have a chronic illness.
•Skilled nursing care facilities, rehabilitative
hospitals, long-term care facilities, home care,
and hospice are examples of tertiary-level
care.
 Types of
Assessment
 Types of Assessment
1. COMPREHENSIVE ASSESSMENT
• examines the patient’s overall health
status.
• The comprehensive assessment
encompasses health problems
experienced by the patient; health
promotion, disease prevention, and
assessment for problems associated with
known risk factors; or assessment for
age- and gender-specific health
problems.
 Types of Assessment
2. PROBLEM-BASED/FOCUSED
ASSESSMENT
• Is problem oriented and may be the initial
assessment or an ongoing assessment.
• Frequently performed on an ongoing
basis to monitor and evaluate the
patient’s progress, interventions, and
response to treatments.
 Types of Assessment
3. Episodic/follow-up assessment:
• This type of assessment is usually done
when a patient is following up with a health
care provider for a previously identified
problem.
 Types of Assessment
4. Shift assessment:
• When individuals are hospitalized, nurses
conduct assessments each shift.
• The purpose of the shift assessment is to
identify changes in a patient’s condition
from baseline.
 Types of Assessment
5. Screening assessment:
• A screening assessment, or screening
examination, is a short examination
focused on disease detection.
• A screening examination might be per-
formed in a health care provider’s office
(as part of a comprehensive examination)
or at a health fair.
Collecting Data
 Collecting Data
1. Subjective data
• are referred to as symptoms.
• are covert and not measurable.
• They reflect what the patient is
experiencing and include thoughts, beliefs,
feelings, sensations, and perceptions.
• The health history is an example of
subjective data.
 Collecting Data
2. Objective data
• are referred to as signs.
• The physical examination and diagnostic
studies are examples of objective data.
• Data sources are either primary or
secondary
 Collecting Data
2. Objective data
•Data sources are either primary or
secondary
– Primary data source –
• The patient.
– Secondary data sources
• are anyone or anything aside from the
patient, including family members, friends,
other healthcare providers, and old medical
records.
 Clinical
Manifestations
• C l i n i c a l
manifestation is
a term often
used to describe
the presenting
s i g n s a n d
s y m p t o m s
experienced by a
patient.
Methods of Data
Collection
Methods of Data Collection
1. Interviews
2. Observation
3. Physical assessment
Methods of Data Collection
1. Interviews
2. Observation
3. Physical
assessment
1. Interviews
2. Observation
3. Physical
assessment
 1. Interviews
.Factors that impair effective communication
with your patient:
• Cultural
• Developmental differences
• Life experiences
 1. Interviews
Therapeutic use of self
• When you use your
interpersonal skills in a
healing way to help your
patient.
 1. Interviews
3 techniques that enhance therapeutic use
of self:
1. Showing empathy- the ability to
understand another’s feelings
2. D e m o n s t r a t i n g a c c e p t a n c e -
nonjudgmental position, patient’s verbal
and nonverbal communication
3. Giving recognition
 Types of Interviews
1. Directive interviews
• are structured with specific questions and
are controlled by the nurse.
• These interviews require less time and
are very effective for obtaining factual
data.
Types of Interviews
2. Nondirective
interviews
• are controlled by the
patient
•These interviews require
more time than directive
interviews but are very
effective at eliciting the
patient’s perceptions and
feelings.
 Types of Questions
1. Closed questions
• are often those that elicit a “yes” or “no”
response.
• This type of question takes little time and
is very effective for factual data.
 Types of Questions
2. Open questions
•Elicit the patient’s perceptions,
•More time is needed for this type of
question.
•They are frequently used in nondirective
interviews.
 Interviewing Techniques
■ Introduce yourself.
■ Don’t rush.Allow enough time for the
interview.
■ Avoid interruptions.
■ Explain that information from the interview is
confidential.
■ Actively listen to what your patient is saying.
■ Maintain eye contact.
 Interviewing Techniques
■ Work at the same level as your patient. Pull
up a chair and sit next to her or him.
■ Don’t invade your patient’s personal space.
Two to 4 feet away is a comfortable distance
for most patients.
■ Explain what you are doing and why.
■ If the patient presents with a problem, begin
by asking questions about that.
 Interviewing Techniques
■ Be nonjudgmental.
■ Avoid “why?” questions; they tend to put
patients on the defensive.
■ Nonverbal behavior is more accurate than
verbal. Take a look at yours—What is it telling
your patient?
■ Take a good look at your patient’s
nonverbal behavior. Is it consistent with what
she or he is telling you?
 Interviewing Techniques
■ Now look at your patient’s nonverbal
behavior another
way. Does it indicate health problems?
■ Never pass up an opportunity to teach.
■ Present reality.
■ Be honest.
■ Provide reassurance and encouragement.
■ Be respectful.
Interviewing Pitfalls
 Interviewing Pitfalls
Avoid the following traps when
interviewing a patient:
1.Leading the patient.
2.Biasing yourself.
3.Letting family members answer for
patient.
4. Asking more than one question at a
time.
 Interviewing Pitfalls
5. Not allowing enough response time.
6. Using medical jargon.
7. Assuming rather than clarifying and
validating.
8. Taking the patient’s responses personally.
9. Feeling personally uncomfortable.
10. Using clichés
 Interviewing Pitfalls
11. Offering false reassurance.
12. Asking persistent or probing questions.
13. Changing the subject.
14. Taking things literally.
15. Giving advice.
16. Jumping to conclusions.
Phases of the Interview
 Phases of the Interview
1. Introductory Phase
• The introductory phase is the time
to introduce yourself to your patient,
put him or her at ease, and explain
the purpose of the interview and the
time frame needed to complete it.
 Phases of the Interview
2. The Working Phase
• The working phase is often where data
collection occurs.
• It is usually very structured; it is also the
longest phase. Make sure you allot enough
time for the working phase.
3. The Termination Phase
• The end of the interview is the termination
phase.
• During this phase, you need to summarize
and restate your findings.
• This provides an opportunity to clarify the
data and share your findings with the patient.
Methods of Data
Collection

2. Observation
 2. Observation
• Observation entails deliberate use of your
senses of sight, smell, and hearing to
collect data.
• Look at both your patient and his or her
environment to detect anything out of the
ordinary.
• Your initial observations may provide clues
to underlying problems.
 2. Observation
Ask yourself:
■ Does the patient show signs of physical or
psychological stress?
■ Does the patient seem comfortable?
■ What is the patient doing?
■ What position is she or he assuming?
■ Are there any abnormal movements?
■ What is the patient’s body language telling you?
■ Is the patient’s verbal language consistent with
his or her nonverbal language?
■ Do you notice any unusual odors?
 2. Observation
§ Do you hear any unusual sounds?
■ Is there anything unusual, unsafe, or risky in the
patient’s environment?
Look for:
■ Facial expression, color changes, breathing
problems
■ Grimacing, guarding, diaphoresis
■ Eye contact
■ Tone of voice and flow of speech
■ Position, orthopnea
 2. Observation
Look for:
■ Grooming and dress
■ Nervousness, restlessness, voluntary/involuntary
movements
■ Unusual odors, such as fruity smell associated
with diabetic ketoacidosis, or foul odors
■ Drainage associated with infection
■ Unusual sounds, such as grunting, wheezing,
rhonchi, or stridor associated with respiratory
problems, or swishing sounds associated with
murmurs
Methods of Data
Collection

3. Physical
Assessment
 3. Physical Assessment
• Physical assessment provides the
objective database.
• It helps you assess your patient’s health
status and identify actual or potential
problems.
 3. Physical Assessment
TECHNIQUES
• Inspection look at your patient and
compare her or his appearance with what
you know as normal.
• Use your sense of smell to detect any
unusual odor that may warrant further
investigation into a possible health problem.
 3. Physical Assessment
TECHNIQUES
• During palpation, use light touch to assess
surface characteristics, to put your patient
at ease, and to convey concern and caring.
Use deep palpation to assess organs and
masses.
 3. Physical Assessment
TECHNIQUES
• During percussion, use direct, indirect, and
fist percussion to assess organ size and
areas of tenderness.
 3. Physical Assessment
TECHNIQUES
• During auscultation, listen to your patient
directly and indirectly to hear sounds
produced by the body.
Validating, Organizing,
and Prioritizing Data
 Validation
• Validation can occur simultaneously with
the assessment process.
• Validating every piece of data is
unrealistic, but you do need to validate any
time you notice an inconsistency or are
unsure of your findings.
 Organizing Data
• After you have validated the assessment
data, you need to organize them.
• Begin by identifying pertinent data—any
findings that are out of the norm and any
findings that identify patient strengths.
 Organizing Data
• Several frameworks
can be used for
organizing data.
• A framework
provides a way of
looking at your
patient and the data.
 Organizing Data
Common frameworks include the
following:
■ Maslow’s Hierarchy of Human Needs:
Organizes data according to the patient’s
basic human needs: physiological, safety and
security, love and belonging, self-esteem, and
self-actualization
 Organizing Data
■ Roy’s Adaptation Theory:
Organizes data according to the patient’s
adaptation to physiological, self-concept,
social role, and interdependence demands.
 Organizing Data
Gordon ’ s Functional Health
Patterns: Organizes data into 11
functional groups that contribute to a
person’s overall health and well-
being, quality of life, and attainment
of human potential.
 Prioritizing Data
• Organizing data will assist you in prioritizing
the patient’s problems.
• When prioritizing, consider the acuity of the
problem, the patient’s perception of the
problem, and the situation at hand.
• Put life-threatening problems at the top of the
list, then problems affecting basic needs that
require prompt attention, and finally, problems
affecting psychosocial needs.