American Nursing Association (ANA)
Has identified assessment as the first standard of nursing practice. The standard (data base ) describe as the systematic, continues collection data about health status of the clients.
Nurse are responsible not only for data collection but for making sure that the data are accessible, communicated and recorded.
Assessment is the collection of data (subjective and objective ) about individual’s health state.
* Subjective data : what the person says bout himself or herself during history taking.
* Objective data : what you as the health professional observe by inspection, palpation, percussion , and auscultation during physical examination
Objectives of Assessment
* The purposes of assessment include surveillance of health status, the identification of latent or occult disease, screening for specific type of disease, and follow-up care.
* Discover the client strengths and coping resources to pinpoint actual problems and to spot factor that place the client at risk for health problems.
Types of Assessment
1- Comprehensive assessment : is usually the initial assessment it very
thorough and includes detailed health history and physical examination and examine the client’s overall health status
2- Focused assessment : is problem oriented and may be the initial assessment or an ongoing assessment
Frequency of Assessment
* Early recommendations suggested that the health assessment should be done each year .
* Other recommendation suggested that the health assessment for the persons under (35) years of age should be every (4 – 5) years,
* Persons from (35 – 45) years of age should be every (2 – 3) years.
* And that any person over (45) years of age undergo a thorough health assessment every year.
Important Of Health Assessment
1- When nurses make health assessment they don’t duplicate medical assessments. the nursing assessment is not to gather data that define underlying pathology & medical problems but it focus on client responses to health problems.
2- Through health assessment the nurse carefully examine the client’s body parts to review their integrity & to determine if abnormalities exist.
3- The nurse relies on data from a variety of sources to reveal patterns of abnormalities which when validated with health assessment findings can indicate significant clinical problems.
4. Health assessment provides a base line, measurement of the client’s existing function abilities, successive examinations used to plan the clients care.
5. Health assessment helps the nurse to diagnose client’s problem & determine the best nursing measures & their management.
6. A complete health assessment involves more detailed review of client’s condition.
7. Accuracy of health assessment influence, the choice of therapies a client receives & the determination of response to those therapies.
Purposes Of Health Assessment
1- Gather data
2- Confirm, or refuse data obtained in the health history
3- To confirm identify nursing diagnoses
4- To make clinical judgments about client’s changing health
5- To evaluate bio-psycho-social and spiritual outcomes of care.
Nursing And Medical Diagnosis
There is a big Difference
* Nursing diagnosis independent role of the nurse
* Nursing diagnoses depends on the client’s problems associated with specific disorder
* Any problem must notice from a holistic view e.g. bio-psycho-social and spiritual relations
Nursing And Medical Diagnosis
Medical diagnoses depends on clinical picture and laboratory findings –
The specialist doctor has a right to diagnose not else –
DM is (hypo or hyperglycemia)
- Impaired skin integrity R/T poor circulation,
- Knowledge deficit R/T low education level
1- The interview
2- Psychosocial assessment
3- Nutritional assessment
4- Assessment of sleep-wakefulness patterns
5- The health history
Communication process focuses on the client’s development, psychological, physiological, socio cultural , and spiritual
- To obtain health history
- To identify development of symptoms
Components Of Nursing Interview
1. Introductory Phase
2. Working Phase
3. Termination Phase
1- Introductory Phase
- Introduces yourself and explains the purpose of the interview to the client.
- Before asking questions let client to feel comfort, privacy and confidentiality
2. Working Phase
*The nurse must listen and observe cues in addition to using critical thinking skills to validate information received from the client.
* The nurse identify client’s problems and goals.
3. Termination Phase
- The nurse summarizes information obtained during the working phase
- Validates problems and goals with the client.
- Making plans to resolve the problems
Communications Techniques During Interview
1- Types of questions :
- Use open ended questions to assess client’s feelings e.g. what, how , which“
- Use closed ended question to obtain facts e.g.” when, did…etc
- Use list to obtain specific answers e.g. is pain sever, dull, sharp.
- Explore all data that deviate from normal e.g. “increase or decrease the problem
2. Types of statements to use:
clarify information, and encourage verbalization
3. Accept the client use silence to recognize thoughts
4. Avoid some communication styles e.g.
- Excessive or not enough eye contact.
- Doing other things during getting history.
- Biased or leading questions e.g. “you don’t feel bad”
- Relying on memory to recall information
5. Specific age variations
Pediatric clients: validate information from parents.
Geriatric clients: use simple words, &assess hearing acuity
6. Emotional variations:
- Be calm with angry clients
- Simply with anxious
- Interest with depressed client
7. Cultural variations:
” In the communication of self and clients”
8. You can use culture broker:
In different languages. And use pictures for non reading clients
- Involves, person’s growth and development throughout his life
- Discuss development stages or crises with the clients to assess relationship between health & illness. “It depends on multiple G&D theories”.
- Nutrition plays a major role in the way an individual looks, feels,& behaves.
- The body ability to fight disease greatly depends on the individual’s nutritional status
Major Goals Of Nutritional Assessment
- Identification of malnutrition.
- Identification of over consumption
- Identification of optimal nutritional health and fitness.
Components of Nutritional Assessment
1. Anthropometric measurement.
2. Biochemical measurement.
3. Clinical examination.
4. Dietary analysis.
* Measurement of size, weight, and proportions of human body
* Measurement includes: height, weight, skin fold thickness, and circumference of various body parts, including the head chest, and arm
Assess body mass index (BMI) to shows a direct and continuous relationship to morbidity mortality in studies of large populations. High ratios of waist to hip circumference are associated with higher risk for illness & decreased life span.
BMI = (wt. in kilograms)
(High in meters) 2
Assess body mass index
* Measure “skin fold thickness (SFT) by ( skin fold calipers) to determine body fat, and to indicate subcutaneous fat and caloric status.
* Skin fold thickness can be measured at variety of body sites, but the non dominant arm is preferred for measurement.
The “SFT is measured on the midpoint of the back of the arm, during relaxation, and repeat measurement several times to take the most accurate measurement
Useful in indicating malnutrition or the development of diseases as a result of over consumption of nutrients. Serum and urine are commonly used for biochemical assessment.
In assessment of malnutrition, commonly used values include:
total lymphocyte count,
albumin, serum transferrin, hemoglobin, and hematocrit… etc. These values taken with anthropometric measurements, give a good overall picture of an individual’s