Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 10 The Assessment Process

Copyright © 2015 Wolters Kluwer All Rights Reserved Assessment as a Process A purposeful, systematic, and dynamic process that is ongoing throughout the nurse’s relationship with individuals in her or his care Involves the collection, validation, analysis, synthesis, organization, and documentation of client health illness information

Copyright © 2015 Wolters Kluwer All Rights Reserved Assessment Comprehensive assessment –Includes a complete health history –Screening: recognize symptoms, risk factors, or emotional difficulties –Develops a holistic understanding of the individual’s problems Focused assessment –A collection of specific information about a particular need –Focused

Copyright © 2015 Wolters Kluwer All Rights Reserved Question Is this statement true or false? A comprehensive assessment includes a complete health history Screening – Recognize symptoms, risk factors, or emotional difficulties

Copyright © 2015 Wolters Kluwer All Rights Reserved Answer False Rationale: A focused assessment includes a collection of specific information about a particular need.

Copyright © 2015 Wolters Kluwer All Rights Reserved Techniques of Data Collection Observations Physical examination Diagnostic testing Assessment interviews –May also include family and friends Collaboration with colleagues

Copyright © 2015 Wolters Kluwer All Rights Reserved Biopsychosocial/Psychiatric/Spiritual Mental Health Nursing Assessment Types and sources of information –Objective data (also called signs) are directly observable and measurable. –Subjective data (symptoms) are neither directly observable nor measurable.

Copyright © 2015 Wolters Kluwer All Rights Reserved Documentation Generally speaking, there are two common approaches to documentation. –Source-oriented –Problem-oriented Information may be entered in the client record in several ways. –Includes fill-in forms, flow sheets, checklists, and narrative notes. –Electronic medical records are becoming more common.

Copyright © 2015 Wolters Kluwer All Rights Reserved Assessment: Biologic Domain Physical examination –Process by which a clinician collects objective information about the client’s health –Includes height and weight, vital signs, examination of all body systems, and diagnostic testing appropriate to the individual’s age, level of risk, and sex

Copyright © 2015 Wolters Kluwer All Rights Reserved Assessment: Psychological Domain Responses to mental health problems or consequences. –An important part of assessing the psychological domain is to explore the individual’s experience of illness. The mental status examination is a systematic assessment of an individual’s appearance, affect, behaviour, and cognitive processes. –Reflects “a snapshot” of the examiner’s observations and impressions at the time of the interview –Evaluates developmental, neurologic, and psychiatric disorders.

Copyright © 2015 Wolters Kluwer All Rights Reserved MMSE Evaluates –Orientation –Registration –Attention and calculation –Recall –Language

Copyright © 2015 Wolters Kluwer All Rights Reserved Question Which of the following features is a biologic assessment rather than a psychological assessment? A. Thought processes B. Cognition and intellectual performance C. Attention and concentration D. Appetite and nutrition

Copyright © 2015 Wolters Kluwer All Rights Reserved Answer D. Appetite and nutrition Rationale: Appetite and nutrition are good indicators of physical health and thus a biologic assessment.

Copyright © 2015 Wolters Kluwer All Rights Reserved Assessment: Psychological Domain (cont.) Includes manifestations of PMH problems/disorders –Mental status –Stress and coping –Risk assessment

Copyright © 2015 Wolters Kluwer All Rights Reserved Suicide Assessment Involves garnering specific details regarding: −Suicidal ideation −Threats of suicide −Suicide attempt To ascertain this information, the nurse asks specific questions about suicidal thoughts.

Copyright © 2015 Wolters Kluwer All Rights Reserved Assaultive or Homicidal Assessment Includes an evaluation of the level of threat an individual poses to others. Of particular importance are delusions or hallucinations that involve harming or killing others. To ascertain this information, the nurse asks specific questions regarding intent to harm someone and plans to harm someone.

Copyright © 2015 Wolters Kluwer All Rights Reserved Social Domain Assessment includes: –Functional status –Ethnic and cultural assessment –Spiritual assessment

Copyright © 2015 Wolters Kluwer All Rights Reserved Question Is the following statement true or false? The phrase “Do you intend to harm someone?” is part of the standard assessment of the likelihood that the patient will attempt suicide.

Copyright © 2015 Wolters Kluwer All Rights Reserved Answer False Rationale: The phrase “Do you intend to harm someone?” is part of the assaultive/homicidal assessment.