Health Assessment and the

Nurse
Outcomes
Define assessment.
Discuss assessment as part of the nursing process.
Discuss assessment, cognitive, psychomotor,
affective/interpersonal, and ethical skills.
Differentiate nursing from medical assessment.
(Continued)
Outcomes
Identify the role of assessment in all levels of
preventive health care.
Differentiate subjective and objective data.
Differentiate primary and secondary data sources.
Describe factors that affect communication.
(Continued)
Outcomes
Discuss cultural effects on communication.
Demonstrate various communication techniques.
Identify the phases of the interview.
Describe data collection methods.
Define the four techniques of physical assessment.
(Continued)
Outcomes
Demonstrate the four techniques of physical
assessment.
Discuss methods used to validate assessment data.
Describe various methods to document assessment
findings.
What Is Assessment?
A data collection process
The first step in the Nursing Process
A continuous process
A method to establish a baseline
(Continued)
Communication
Nonverbal messages and touch
Vocal cues and paralinguistics: quality of voice,
inflection, tone, intensity, and speed
Action cues & kinetics: body movements, posture,
arm position, hand gestures, facial expression, eye
contact
(Continued)
- is defined as a process of generating
and transmitting meaning and it
includes verbal and non verbal
communication
Communication
Object cues: grooming, dress
Personal space: public, social, and personal
Cultural considerations

Communication Techniques
Affirmation/ Facilitation
- Acknowledge patient's
response

non-verbal gesture such as:
nodding, or sitting up and
leaning forward, encourage
patient to continue.
Verbal cues such as saying: ah
ha, go on, tell me more.
Silence
- it allows pt to collect her/his
thoughts before responding
& help prevents hasty
responses that may be
inaccurate.
- it gives you more time to
think and plan your
responses.

Communication Techniques
Clarifying
- if you are unsure or
confused about what
your pt is saying,
rephrase what she/he
said & then ask the pt
to clarify.
Phrases Like:
Let me see if i have this
right, or I want to
make sure i'm clear on
this, or I'm not sure
what you mean.
Restating
- restating the pt's main idea shows
him that you are listening.
- allows acknowledging pt's feeling
and encourages further discussion
- it also helps clarify and validate
what your pt has said and may help
identify teaching needs.
For example:
I take a water pill every day for my blood
pressure,
your response might be, I see you take Lasix
every morning for your blood pressure.
if the pt replies No, I take water pill every
morning,

Communication Techniques
Active Listening
- Pay attention
- maintain eye contact
- it conveys interest and
acceptance

Broad or general
Opening
- use open-ended questions
such as: What would
you like to talk about?


Reflection
- it allows you to acknowledge
your pt's feelings, encouraging
further discussion.
- when your pt expresses a
thought or feeling, you echo it
back, usually in a form of
question.
For example:
I am so afraid of having surgery

your response:
You're afraid of having surgery?


Communication Techniques
Humor
- it can be very therapeutic
when used in the right
context.
- it can reduced anxiety, help
pts cope more effectively,
put things into perspective,
abd decrease social
distance
Informing
- giving information allows
your pt to be involved in
his/her healthcare
decuisions.
Redirecting
- helps keep the communication
goal-directed.
- it is especially useful if pt goes
off on tangent
For example:
Getting back to what brought you to the
hospital
Focusing
- allows you to hone in on specific
area, encouraging further
discussion
For example:
You said your mother & sister had breast cancer?
or Do you do BSE, & have you ever had a
mammogram?
Communication Techniques
Sharing Perceptions
- you give your interpretation
of what has been said in
order to clarify things and
prevent misunderstanding.
For example:
You said you weren't upset, but you're
crying
Identifying Themes
- may help your pt make a
connection & focus on the
major theme.
For example:
From what you've told me, it sounds like
every time you were discharged from the
hospital to home you had problem
Sequencing Events
- helps her/him place the events, in
proper order
- start at the beginning & work
through the event until the
conclusion.
For example:
What happened before the problem started? Then
what happened? How did it end?
Suggesting
- presenting alternative ideas gives
pt options.
- helpful if pt having difficulty
verbalizing his/her feelings
For example:
I've tried so hard to lose weight, but I can't
Have you tried combining diet and exercise?
Communication Techniques
Presenting Reality
- if the pt seems to be
exaggerating or contradicting
the facts, help her/him
reexamine what has already
been said & be more realistic.

For example:
I waited all day for someone to answer my
call light
All day?
Summarizing
- is useful at the conclusion of
a major section of the
interview.
- it allows the pt to clarify any
miosconceptions you may
have
For example:
Let me see if I have this correct; you came to
the hospital with chest pain, which started
an hour ago, after eating lunch.

How You Communicate
Genuineness
- be open, honest and sincere
- pt can detect a less-than-honest response or
inconsistencies between your verbal & non-
verbal behavior
Respect
- everyone should be respected as a person of worth & value
- you need to be non-judgemental
- you may not always agree with your pt's decisions or like or
approve of his/her behavior, but everyone needs to feel
accepted as a unique individual
How You Communicate
Empathy
- is knowing what your pt means &
understanding how she/he feels
- showing empathy acknowledges your
pt's feelings; shows acceptance, care,
and concern; and foster open
communication
- phrases that recognize your pt's
feeling help build a trusting
relationship
For example:
That must have been very difficult for you
What Is Assessment?
A systematic process
Identifies patients strengths and
limitations
Involves collecting, validating,
and clustering data
Purpose of Assessment
Collect pertinent patient health status
data
Identify abnormal findings
Identify patients strengths and coping
resources
(Continued)
Purpose of Assessment
To collect date pertinent to the pt's
health status
To identify deviations from normal
To discover the pt's strengths and
coping resources
Pinpoint actual health problems
Identify risk factors for health
problems
Skills of Assessment
Cognitive Skills
Psychomotor
Interpersonal/Affective Skills
Ethical Skills
Assessment Skills
Cognitive Skills
Assessment is a thinking process
Critical thinking
Inductive and deductive reasoning
Clinical decision-making
(Continued)
theoritical knowledge base
- enables you to assess your pt holistically
- enables you to differentiate normal from abnormal findings
- to identify and prioritize actual and potential problems
Assessment Skills
Cognitive Skills
Critical thinking
- is a complex thinking process that has been defined in
many ways;
Critical thinking is reflective, reasonable thinking (Ennis,
1985).
It is not just doing, it is asking why?.
It involves inquiry, interpretation, analysis and synthesis.
(Continued)
Assessment Skills
Cognitive Skills
Clinical Decision Making
- as you collect data, you will make clinical
decisions as to its relevance.
- look for cues and make inferences

(Continued)
Assessment Skills
Problem-Solving Skills
Reflexive thinking is automatic, without conscious
deliberation, and comes with experience.
Trial and error is hit-or-miss thinking random, not
systematic and inefficient.
Scientific method is systematic, critical-thinking
approach to problem solving.
Intuition is a problem-solving method that develops
through experience, in which theory and practice are
intertwined.
(Continued)
Assessment Skills
Psychomotor Skills
Assessment is a doing process.
Skills needed to perform the four techniques of
physical assessment

Interpersonal/Affective Skills
Assessment is a feeling process.
Affective skills needed to develop caring, therapeutic
nursepatient relationships
(Continued)
Assessment Skills
Ethical Skills
Assessment is being responsible and accountable.
Responsible & accountable for practice
Patient advocate
Respect patients rights
Assure confidentiality
Assignment
The Code for Nurses in a short bond paper verdana 12.

Difference Between Nursing & Medicine
Nursings Goal
To diagnose and treat human responses to actual or
potential health problems
- nursing's aim is to help the patient reach her/his optimal level of
wellness
Medicines Goal
To diagnose and treat disease
Assignment
The NJPC's Element of Collaboration
Levels of Preventive Care
Primary
To focus on health promotion and illness prevention
- example: health fairs, immunizations, and nutritional instructions.
Secondary
To focus on early detection, prompt intervention, and
health maintenance.
- it addresses acute health problems seen with inpatient
hospitalization
Levels of Preventive Care
Tertiary
To focus on rehabilitation and extended care
- pt's health status is generally more stable than in secondary
care, pt usually have a chronic illness.

Examples: Skilled Nursing care Facilities
Rehabilitative hospitals
long-term facilities
home care
and hospice
Comprehensive Assessment
- initial assessment
- it is very thorough and includes a detailed health history
and physical examination.
- examine the pt's qverall health status.

Focused Assessment
- problem oriented and may be intial assessment or ongoing
assessment
- is frequently performed on an ongoing basis to monitor
and evaluate the pt's progress, interventions, and response
to treatments
Types
Assessment Data
Subjective
-Covert, not measurable
- reflects what the pt is experiencing & include
thoughts, belief, feelings, sensations, & perceptions
- referred to as symptoms
Objective
- Overt, measurable
- referred to as signs: physical examination &
diagnostic studies.
Primary Sources
patient

Secondary Sources

anyone or anything aside from the patient, including
family members, friends, other healthcare providers,
and old medical records.
Methods of Data Collection:
The Interview
Is usually structured communication
intended to obtain subjective data
Most effective when taking the health history
Methods of Data Collection:
The Interview
Types of interviews:
Directive interviews are structured with specific
questions & are controlled by the nurse
- require less time and are very effective
obtaining factual data.
Non-directive interviews
- are controlled by the patient
- require more time but are very effective at
eliciting the pt's perceptions and feeling.

Types of questions:
Open pt perception, what brought you to the
hospital? (non directive interviews)
Closed are often those that elicit a yes or no
response Do you have pain? (directive
interview)
Interviewing tips/pitfalls - assignment
Methods of Data Collection:
Assignment interviewing Technique
Interviewing tips/pitfalls
Leading the patient
Biasing yourself
Letting family members answer
for patient
Asking more than one question at
a time
Not allowing enough response
time
Using medical jargon
Assuming rather than clarifying
and validating
Taking the patient's responses
personally
Methods of Data Collection:
Interviewing tips/pitfalls
Feeling personally
uncomfortable
Using clichs
Offering false reassurance
Asking persistent or probing
questions
Changing the subject
Taking thing literally
Giving advice
Jumping to conclusion
Phases of the Interview
The Introductory Phase
Introduce self
Put patient at ease
Explain purpose of interview
Explain time frame
Reassure that the information collected is confidential
Phases of the Interview
The Working Phase
Data collection, structured
Longest phase
Listening is very crucial
The Termination Phase
End of interview
Summarize & restate findings
Methods of Data Collection:
Observation
Entails deliberate use all of your senses



Look at patient and environment to detect anything
out of ordinary
What data can you collect through observation?
Methods of Data Collection:
Inspection


Palpation

Percussion


Auscultation
Physical Assessment
- it helps assess pt's health status & identify actual or
potential problem
Validation
- once you have collected the data, you need to validate them
to ensure their accuracy.

Organizing Data
- after validating the assessment data, you need to organize
them.
- begin identifying pertinent data any findings that are out
of norm and any findings that identify pt strengths
- clustering relevant data gives meaning to the data, this will
be the basis for formulating nursing diagnoses for the pt
Methods of Data Collection:
Organizing data
Several frameworks
- it provides a way looking
at pt and the data.

Maslow's Hierarchy of
Human Needs
-




Organizing data

Roy's Adaptation theory




Gordon's 11 Functional Patterns
Marjorie Gordon (1987) proposed functional health patterns as a guide for establishing a
comprehensive nursing data base.
Health Perception and Health Management
- Data collection is focused on the person's perceived level of health and well-
being, and on practices for maintaining health.
- Habits that may be detrimental to health are also evaluated, including smoking
and alcohol or drug use.
- Actual or potential problems related to safety and health management may be
identified as well as needs for modifications in the home or needs for
continued care in the home.

Nutrition and Metabolism
- Assessment is focused on the pattern of food and fluid consumption relative to
metabolic need.
- The adequacy of local nutrient supplies is evaluated.
- Actual or potential problems related to fluid balance, tissue integrity, and host
defenses may be identified as well as problems with the gastrointestinal
system.
Gordon's 11 Functional Patterns
Elimination
- Data collection is focused on excretory patterns (bowel, bladder, skin).
- Excretory problems such as incontinence, constipation, diarrhea, and urinary
retention may be identified.

Activity and Exercise
- Assessment is focused on the activities of daily living requiring energy
expenditure, including self-care activities, exercise, and leisure activities.
- The status of major body systems involved with activity and exercise is
evaluated, including the respiratory, cardiovascular, and musculoskeletal
systems.
Cognition and Perception
- Assessment is focused on the ability to comprehend and use information and on
the sensory functions.
- Data pertaining to neurologic functions are collected to aid this process.
- Sensory experiences such as pain and altered sensory input may be identified
and further evaluated.
Gordon's 11 Functional Patterns
Sleep and Rest
- Assessment is focused on the person's sleep, rest, and relaxation practices.
- Dysfunctional sleep patterns, fatigue, and responses to sleep deprivation may
be identified.

Self-Perception and Self-Concept
- Assessment is focused on the person's attitudes toward self, including identity,
body image, and sense of self-worth.
- The person's level of self-esteem and response to threats to his or her self-
concept may be identified.

Roles and Relationships
- Assessment is focused on the person's roles in the world and relationships with
others.
- Satisfaction with roles, role strain, or dysfunctional relationships may be
further evaluated.

Gordon's 11 Functional Patterns
Sexuality and Reproduction
- Assessment is focused on the person's satisfaction or dissatisfaction with
sexuality patterns and reproductive functions.
- Concerns with sexuality may he identified.

Coping and Stress Tolerance
- Assessment is focused on the person's perception of stress and on his or her
coping strategies Support systems are evaluated, and symptoms of stress are
noted.
- The effectiveness of a person's coping strategies in terms of stress tolerance
may be further evaluated.

Values and Belief
- Assessment is focused on the person's values and beliefs (including spiritual
beliefs), or on the goals that guide his or her choices or decisions.
NANDA- Unitary Person Framework
- organizes data based on the concept that a person is an open system in
constant interaction with the environment.
Data Collection Pitfalls
Omitting data -
Misinterpreting data
Hasty interpretation
Irrelevant data
Failure to follow-up
Poor communication
Prioritizing Data
Primary or Top Priority
Life-threatening problems
Secondary
Require prompt attention to prevent
further progression or deterioration
Tertiary
Important, but do not require immediate
attention

Documenting Data
Methods
SOAPIE
DAR
PIE
Narrative
Documentation tips