1. Nursing Assessment

2. Nursing assessment thinking about what information to collect
collecting information
thinking about the significance of that information
drawing conclusions about how the patient is responding to his or health or illness condition

3. Nursing assessment: 2 steps
Collecting and verifying data from the patient and family members
Patient: the primary source of information
Family, medical records, other health professionals: secondary sources of information
Analyzing the data to determine the plan of care for the patient

4. Databases
The purpose of nursing assessment is to develop a database about the client’s health status
Patient’s perceived needs and health problems
Patient’s responses to these problems
The database also provides other information about the patient’s:
Related experiences
Health practices
Goals
Values
Expectations about the health care system

5. Assessment-six steps collecting data
identifying cues and making inferences
validating data
organizing (clustering data)
identifying patterns/testing first impressions
reporting and recording data

6. Database vs. focus assessment
Database assessment
Standardized start-of-care assessment tool for each patient – includes information about all body systems and issues important to the patient’s health
Comprehensive and accurate data base assessment system that is standardized and reproducible
Focus assessment
Data gathered to determine the status of a specific condition
For example: a diabetic’s blood sugar history or a patient’s eating habits

7. Objective data Observations or measurements that are made by the nurse
Examples:
Size of a wound or lesion
Blood pressure, temperature, pulse rate
Amount of urine output
If it can be measured with equipment or sensors, it is objective data

8. Subjective data Data that can only be provided by the patient
Feelings, impressions, sensations, beliefs, attitudes
Anxiety, pain, mental stress, relief, joy, grief
Only patients can provide subjective data about their feelings, although some problems may result in physiological changes that can be measured objectively
For example: severe pain will often cause increased heart rate and blood pressure

9. Patient interview Good for getting information about:
“What brings you here” (chief complaint)
Health history
Introduce yourself
Be professional but be pleasant
Be sure to state your position (RN, student nurse, etc.)
Patients usually love student nurses- don’t be afraid to let them know that you are a student!

10. Patient interview
Sometimes patients are not too keen on admitting why they are there-
Patients sometimes have embarrassing reasons for seeking health care
Don’t be judgmental, don’t show emotion- just be professional and supportive to the patient
You can let your emotions out later, away from the patient!

11. Patient interview
It is usually best to do the health history first, before doing a physical examination
The patient will get to know you a bit and start to become comfortable with you before invasive/intrusive examination procedures begin
Try to do the patient interview where you won’t be interrupted or overheard

12. Patient interview
Try to be yourself, and relax so that you can put the patient at ease as much as possible
If you appear stiff and tense, the patient will feel the same way
Go through your questions carefully, and pay attention to the patient’s answers
Don’t become so engrossed in writing down answers that you miss the patient’s body language

13. Putting patients at ease
When I meet new patients who are anxious, I try to find some area that we have in common- crossword puzzles, TV, movies, whatever- to help put them at ease
I also have a variety of uniforms with cartoon characters on them (Garfield, Snoopy, Bugs Bunny) that help to break the ice with new or anxious patients
Once patients are comfortable talking with you about a safe topic, then they will usually be more comfortable talking about topics of a more sensitive nature

14. A note about working with patients
I think that the best part of nursing is the nurse-patient relationship
When the nurse realizes that the patient is a person with real thoughts and feelings, and the patient realizes the same about the nurse, a special connection forms
That connection is what makes nursing really great for me… An interaction begins that goes beyond a job- it becomes a helping relationship between two people that leaves the nurse and the patient better because of the encounter

15. Patients
When working with patients and their families, you often will get front-row seats to some of the best and worst times of their lives
It is important to be supportive and empathetic but not become dragged down by their grief or loss
Patients and families may get angry, upset or frantic- Be supportive and professional.
Sometimes it helps to just let the patient or family vent their feelings. Do what you can and don’t take it personally.

16. Validating (verifying) data
verifying that your data is factual and complete
need to avoid:
making assumptions
missing key information
misunderstanding situation
jumping to conclusion or focusing in the wrong direction
making errors in problem identification

17. Once you have your data verified…
You need to organize it!
Some facilities will have forms to fill out that have everything organized.
Sometimes you will have to do it yourself.
There are lots of ways to organize your data
Can organize head to toe (useful for physical assessments)
Or into groups like Gordon’s Functional Health Patterns

18. Gordon’s Functional Health Patterns -may be used to organize assessment data
Health perception & management
Activity & exercise
Nutrition & metabolism
Elimination
Sleep and Rest
Cognition & perception
Self-perception & self-concept
Roles & relationships
Coping & stress management
Sexuality & reproduction
Values & beliefs

19. Analyzing data
Once you have your data organized, you will want to look through it to identify patterns
For instance- you might notice that the patient…
Smokes 2 packs per day
Has a congested cough and wheezes
Gets short of breath easily
This patient obviously has some respiratory issues going on, so you can:
Consider respiratory-related nursing diagnoses
Do some additional physical assessments- check the patient’s oxygen saturation, look for nail clubbing, etc.
This is where critical thinking comes in!!!

20. Documenting
Be sure to document all of your findings from the interview/health history and physical examination.
Make notes while you are doing the interview and assessment, and save the rest for afterward
Patients don’t like to sit and watch you write long notes about them
When you are at clinical - any abnormal, unusual, or unexpected findings must be reported to your instructor in addition to being documented in the patient’s chart!