Key Concepts, Chapter 11, Assessing

Assessing is the systematic and continuous collection, analysis, validation, and

communication of patient data, or information. These data reflect how health functioning

is enhanced by health promotion or compromised by illness and injury. A database

includes all the pertinent patient information collected by the nurse and other health care

professionals.
Since the entire nursing process rests on the initial and ongoing assessment of the patient,

it is imperative to use excellent critical thinking and clinical reasoning skills when

gathering, analyzing, validating, and communicating data.

To enable sound clinical reasoning, nursing assessments should have the following

characteristics: purposeful, prioritized, complete, systematic, accurate, relevant, and

recorded in a standard format.

Nursing assessments include the comprehensive initial assessment, the focused

assessment, the emergency assessment, and the time-lapsed assessment.

When preparing for data collection, establishing assessment priorities and systematically

structuring data collection are two important considerations. The purpose of the

assessment offers the best guideline about what type and how much data to collect.

Assessment priorities are influenced by the patients health orientation, developmental

stage, culture, and need for nursing.

There are two types of data: subjective and objective. Subjective data are information

perceived only by the affected person; these data cannot be perceived or verified by

another person. Objective data are observable and measurable data that can be seen,

heard, or felt by someone other than the person experiencing them.

 The patient is the primary and usually the best source of information. Unless specified

otherwise, it is assumed that the data recorded in the nursing history were collected from

the patient. Other sources of information include family and significant others, the patient

record, assessment technology, other health care professionals, and the nursing and other

literature.

The nursing history identifies the patients health status, strengths, health problems,

health risks, and need for nursing care. The nurse obtains a nursing history by

interviewing the patient. An interview is a planned communication with four phases: the

preparatory phase, introduction, working phase, and termination.

The nurse may also perform a nursing physical examination to collect data. The nursing

physical assessment involves the examination of all body systems, review of systems

(ROS), in a systematic manner, commonly using a head-to-toe format. Four methods are

used to collect data during a physical assessment: inspection, palpation, percussion, and

auscultation.
Observation is a key nursing skill, whether gathering the nursing history or performing

the physical examination. Observation is the conscious and deliberate use of the five

senses to gather data.

Common problems in data collection include inappropriate organization of the database,

omission of pertinent data, inclusion of irrelevant or duplicate data, erroneous or

misinterpreted data, failure to establish rapport and partnership with the patient, recording

an interpretation of data rather than observed behavior, and failure to update the database.

Nurses now use the language of cues and inferences to describe the early analysis of data.

The collective subjective and objective data you identify is a cue that something may be

wrong. The judgment you reach about the cue is an inference.

 Validation is the act of confirming or verifying. The purpose of validating is to keep data

as free from error, bias, and misinterpretation as possible. Validation is an important part

of assessment because invalid information can lead to inappropriate nursing care.

Once you have organized (clustered) your data according to the purpose of your

assessment, you look for and test your initial impressions about patterns of human

functioning.

The patient data collected by the nurse, both initially and as patient contact continues, are

of no benefit to the patient and the health care team unless they are appropriately

communicated. Appropriate communication involves correct timing and proper

documentation.