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ASSESSMENTNursing process is a systematic method that directs the nurse and
patient’s together to accomplish the following.
(i) Assess the patient to determine the need for nursing care.
(ii) Determine the nursing diagnosis for actual and potential health
problems.
(iii) Identify expected outcomes and plan care.
(iv) Implement the care.
(v) Evaluate the results.
Definition:
The Nursing process is used to identify, diagnose and treat human
responses to health and illness. (By ANA)
Nursing Process an Overview:
AssessmentGather information about client’s condition.
EvaluationDetermine if goals met and outcomes achieved.
DiagnosisIdentify the client’s problems.
ImplementationPerform the nursing actions as per the planning.
Planning Set goals of care and
desired outcomes. Identify the
appropriate nursing actions.
Nursing process is a continuous process which involves the following
five series of steps.
(i) Assessment
(ii) Planning
(iii) Diagnosis
(iv) Implementation
(v) Evaluation.
Nursing Assessment
It is the first phase of nursing process.
Definition
Nursing Assessment is the systematic and continuous collection,
validation and communication of patient’s data.
Nursing Assessment is the gathering of information about a patient’s
physiological, psychological, sociological and spiritual status.
Purposes of Nursing Assessment
o To gather data about the individual, family or community.
o To establish the base line information about the client.
o To determine the client’s normal function.
o To determine the presence or absence of dysfunction.
o To determine the client’s risk for dysfunction.
o To determine the client’s strengths.
o To identify the actual and potential health problems.
o To provide data for the diagnosis phase.
Types of Nursing Assessments
(i) Initial Assessment
It is performed shortly after the patient is admitted to the hospital.
Here the nurse gathers the information about all aspects of the patient’s
health status. This information is otherwise called Base line data. It tells
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about the patient’s condition before investigations begin and it serves as
the basis for identifying the problems.
Purpose
It is done to establish a complete data base for problem
identification and care planning.
The nurse collects data related to all the aspects of patient’s health.
(ii) Focused Assessment
The nurse gathers data about a specific problem that has already
been identified. It is used to gather information that is specific to determine
the status of an actual or potential problems. It is an ongoing assessment,
helps to identify an actual or potential problems. The nurse has to perform
periodic focus assessment to monitor the status.
The questions may be
What ate the symptoms?
When did they start?
What makes the symptoms better or worse?
Whether the client takes any remedies (Medical/Natural) for the
symptoms?
Purpose
The purpose of the Focused Assessment is to identify new or over
looked problems.
Guidelines to be followed while performing focus assessment
1. Are these observable signs and symptoms that demonstrate that the
problem exists right now? Are these symptoms getting better, worse
or staying the same?
2. Are there factors contributing to the problem that can be reduced,
controlled or eliminated to alleviate or prevent the problem?
3. How does the patient feel about managing or preventing the
problem?
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(iii) Emergency Assessment
This is performed by the nurse when there is a physiological or
psychological crisis
(e.g. violence). Emergency assessment takes place in life threatening
situations when the preservation of life is in the top priority.
It is done for the patients
1. Who have difficulties involve Airway, Breathing and circulation
2. Suicidal thoughts
Emergency assessment focuses on a few essential health patterns and it is
not a comprehensive assessment.
Purpose
To identify life threatening problems.
(iv) Time Lapsed Assessment
It is performed to compare a patient’s current status to base line data
obtained earlier.
It is done mostly to the patients in residential settings and those who
received nursing care over a prolonged period of care. It is used to detect
the changes in all functional health patterns. There is a several months
gaps between the two assessments.
Purpose
To re assess health status and to make necessary revisions in patient
care.
Uniqueness of Nursing Assessment:
When nurses performing assessment they should not duplicate the
medical assessment.
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Medical Assessment
Targeting data pointing out to pathological conditions.
Nursing Assessment
Focus on the patient’s responses to actual or potential health
problems.
Steps in the Nursing Assessment
(i) Collecting data.
(ii) Validating data.
(iii) Organizing data.
(iv) Identifying patterns.
(v) Communicating/Recording data.
(i) Collecting data
Gathering information about patient or client. Data collection begins
when the client approaches the health care system in first time. This could
be collected from the out patient department it self. At the time of
admission, a comprehensive nursing assessment is accomplished, and
pertinent data are documented in the chart.
Characteristics of data
Purposeful
The nurse should identify the purpose of the nursing assessment
(comprehensive, focused, emergency, time lapsed) and gather the data.
Complete
The nurse should collect the complete data needed to understand the
patient health problem and to develop the nursing care plan.
Factual and Accurate
While collecting the data the nurse should continually verify what she
hear, with what she observe, using other senses and validating all
questionable data. The nurse should check the data provided by the patient
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or care giver is reliable. It is best that the assessor should document the
observed behaviour rather than the interpreted behaviour.
E.g.
Observed behaviour - Patient frequently observed lying with his face to
the wall. Attempts to engage him in conversation
fail. He refused lunch today and ate only soup for
dinner.
Interpreted behaviour - Patient is depressed
Relevant
During collection of data the nurse should determine what type of
data and how much data need to be collected from the patients.
Resources for Data Collection
Patient/client (primary source).
Family/significant members.
Nursing records.
Medical records.
Verbal/written consultations (with other health care professionals).
Records of diagnostic studies.
Relevant literature.
Nurse’s experience.
Types of data
(a)Subjective data
Information perceived only by the affected person.
E.g. Feeling of nervousness, nausea, pain;
(b) Objective data
Observation or measurement made by the observer.
E.g. Wound assessment, identification of temperature,
localized body rash, etc.
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The measurement of the objective data is based on an
accepted standard.
E.g.
Fahrenheit or Celsius thermometer.
Centimeter on measuring tape.
Blood pressure.
Interview
It is the first step to collect the subjective information from the client.
Interview is an organized conversation with the client to obtain the client’s
health history and information about the current illness.
Advantages of an interview
1. Nurse can explain her role and the role of others during the care to
the client.
2. Establish a sense of carry for the client as an individual.
3. Establish a therapeutic relationship with the client.
4. Gain insight about the client’s concerns and worries.
5. Determine the client’s goals and expectations of the health care
system.
6. Obtain cues about which parts of the data collection phase require
further in-depth investigation.
Phases of Interview
1. Preparatory/orientation Phase:
2. Working Phase
3. Termination Phase
1. Preparatory / Orientation Phase
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Before starting interview, the nurse prepares to meet the patient’s by
reading current and past records and reports.
Nurse should approach the patient’s with open mind and to be
sensitive to the human needs.
Ensure that the environment is private and relaxed.
The seating arrangements and the distance between the patient and
nurse should be adequate.
The nurse should initiate the interview by stating her Name & Status
and the purpose of interview.
Assure the patient about the confidentiality.
2. Working Phase
During this phase the nurse gathers all information about the client’s
health status. In this phase the nurse should use a variety of
communication skills such as listening, paraphrasing, focusing,
summarizing and clarifying and her critical thinking skills.
3. Termination Phase
Nurse should give clue that the interview is going to end.
Summarize all the important points and check with the client that the
summary is accurate.
Interview should be completed in a friendly manner.
Tips for an successful Interview
To establish a rapport
Ensure privacy
Use the person’s name
Explain your purpose
Use good eye contact
Don’t hurry
To observe
Use your senses
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Notice general appearance
Notice body language
Notice Interaction Patterns
To ask questions
Ask about the person’s main problem first
Use the terminology that the person understands
Use open ended questions
Use reflection
Don’t start with personal or delicate questions
Use an organized assessment tool to prevent omissions
To Listen
Be an active listener
Allow the person to finish sentences
Be patient if the person has a memory block
Give your full attention
For clarification, summarize and restate what has been said
Components of Data Collection
Nursing history.
Physical/psychological examination.
Nursing History
Nursing history is a data collected about the client’s current level of
wellness, including a review of body systems, family and health history,
socio cultural history, spiritual health, mental and emotional reactions to
illness.
Taking nursing history prior to the physical examination allows a
nurse to establish a rapport with the patient and helps to gain the
confidence of the patient.
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Dimensions for Health History
Client Health History
Physical and developmentalo Perception of health status
Past health problems/therapies Risk factors. Activity and coordination. Review of systems. Developmental stage. Growth and malnutrition. Occupation. Ability to complete activities of daily living (ADL).
Intellectual Intellectual performance. Problem solving. Educational level. Communication patterns. Attention span. Long term and recent
memory.
Spiritual Beliefs and meaning. Religious experiences. Rituals and practices. Fellowship. Courage.
Emotional Behavioral and
emotional status. Support systems. Self concept. Body image. Mood. Sexuality. Coping mechanisms.
Social Financial status. Recreational activities. Primary language. Cultural influences. Community resources. Environmental risk
factors. Social relationships. Family structure and
support.
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Components of a Nursing History
I. Biographic data
1. Name :
2. Age : …………………Year
3. Sex : Male / Female
4. Ward :
5. IP No :
6. Marital Status : Single/Married/Separated/
Divorced/Widowed
7. Education : Illiterate/primary/High School/College
8. Occupation :
9. Income :
10. Religion : Hindu/Muslim/Christian/Others (Specify)
11. Language Known : Tamil/Hindi/Malayalam/Kannada/Telugu
English/Others (Specify)
12. Address :
13. Diagnosis :
14. Date of Admission :
15. Date of Surgery :
16. Nature of Surgery :
17. Post O.P. Day :
18. Date of Discharge :
19. Informant :
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II. Introduction
III. Socio Economic Background
Write whether patient is from a village/town/city. Is he/she living in rented
house or own house/ No. of rooms, doors, windows/water facility/electricity
facility/toilet facility/income of the family/bread winner of the family/drainage
facility, kitchen garden and pet animals.
IV. Family Health History
Patient
S. No Name Relationship
to patient
Age Sex Education Occupation Health
Status
(a) Family Composition
(b) Family Medical History
To ascertain risk factors for certain diseases the ages of siblings, parents,
and grand parents and their current state of health or (if they are deceased) the
cause of death are obtained. Particular attention should be given to disorders such
as heart disease, cancer, diabetes, hypertension, obesity, allergies, arthritis,
tuberculosis, bleeding, alcoholism, and any mental health disorders.
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V. Personal History
(a) Personal Habits
The amount, frequency, and duration of substance use (tobacco chewing,
cigarette smoking, alcohol, coffee, cola, tea)
(b) Diet
Number of meals and snacks/day
Vegetarian/Non Vegetarian
Allergies to any food item
Nutritional assessment 24 hours recall and recommended diet plan (for
patients on therapeutic diet)
Likes & Dislikes of food
(c) Sleep/Rest Patterns
Usual daily sleep/number of hours per day & night, wake times, difficulties
sleeping, and remedies used for difficulties.
(d) Activities of daily living
Any difficulties experienced in the basic activities of eating, brushing,
bathing, grooming, dressing, elimination, and locomotion.
(e) Elimination
Bowel habits - Number of times per day
Bladder habits - Number of times during day and night
(f) Hobbies/Interests
Reading books/Watching TV/Playing/Listening to music/Others (Specify)
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(g) Menstrual History
1. Puberty attained on :
2. Duration of cycle :
3. Amount of flow :
4. Regular/Irregular :
5. Any abnormalities :
6. Any pain :
(h) Obstetrical History
Number of pregnancy, number of delivery, abortion, still birth, number of
live child, number of death, any complications.
VI. History of Present Illness
(a) Present Medical History
When the symptoms started
Whether the onset of symptoms were sudden or gradual
How often the problem occurs
Exact location of the distress
Character of the complaint (e.g., intensity of pain or quality of sputum,
emesis or discharge)
Activity in which the client was involved when the problem occurred
Phenomena or symptoms associated with the chief complaint
Factors that aggravate or alleviate the problem
(b) Present Surgical History
Date and type of procedure performed, name of surgeon, client’s reaction,
events and its outcome.
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VII. History of Past Illness
(a) Past Medical History
Previous hospitalization (medical/surgical)
Any communicable disease/genetic disorders
On treatment for any disease
Immunization if any
Allergies: H/O any drug allergy
(b) Past Surgical History/Present Surgical History
Nature of Surgery
Date of Surgery
Name of Surgeon
Physical Assessment
The physical examination is a systematic data collection
method that uses the senses of sight, hearing, smell and touch to detect
health problems.
Physician Physical Assessment - To identify pathologic conditions and
their causes.
Nurses Physical Assessment - Focuses primarily on the patients
functional abilities.
eg. Neurological deficit.
Techniques of Physical Assessment
Inspection
Inspection is the systematic, deliberate visual examination of the
entire body region. Inspection gives information about size, shape, color,
texture, symmetry, position and deformities. Inspection should be
conducted in a well lighted setting. It is enhanced with special instruments
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such as penlight, otoscope, opthalmoscope, various specula (nasal and
vaginal) etc. tongue plate, marking pen, tape measure, skin fold, calipers
and eye charts)
Palpation
It is one method of physical assessment performed by use of touch.
During palpation, exert varying amounts of pressure to determine
information about masses, pulsation, organ size, tenderness or pain,
swelling, tissue firmness and elasticity, vibration, temperature and
moisture. Palpation is also done to assess masses for position, size, shape,
consistency and mobility. The patient should be placed in a comfortable
position. Before palpating, ask the patient to indicate tender areas, palpate
tender areas last.
Levels of Palpation:
Light Palpation:
Depress the underlying tissue approximately 1 to 2 cm.
Deep Palpation:
Depress the underlying tissue approximately 4 to 5 cms, proceeding
cautiously, prolonged pressure can cause injury to the internal organs.
Bi-Manual Palpation:
Place one hand lightly on the client’s skin (the sensing hand) place
the other hand (active hand) over the sensing hand to apply pressure. The
sensing hand does not apply direct pressure and remains sensitive to
underlying organ characteristics.
1. We can find out the variation by positioning one hand or stabilizes on
organ while other hand palpates. By using this method the nurse can
able to identify the variations in liver, spleen, kidney, breast and
uterus.
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2. The nurse can trap the structures that move between the two hands.
Example palpation of kidney while respiration.
Precautions:
Do not palpate the carotid or arteries simultaneously because there is
a possibility of restricting the blood flow to the brain.
Percussion:
This is used to assess tissue density with sound produced from
striking the skin. Percussion of body structures containing a, fluids and
solids produces various sounds, depending on density.
Types of sounds:
1. Flatness
A soft, high pitched, short sound produced by very dense tissue such
as muscle.
2. Dullness
A soft to moderately loud sound of moderate pitch and duration. It
produced by less dense mostly fluid tissue such as liver and spleen.
3. Resonance
It is a moderate to loud, low pitch sound with long duration results
from the air filled tissue of the normal lungs.
4. Hyperresonance:
It is a very loud low pitched sound with longer duration than
resonance produced by the over inflated, air filled lungs of the person. E.g.,
pulmonary emphysema.
5. Tympany:
It is a loud, high pitch long sound with a drum like musical quality
results from enclosed, air containing structures, such as the stomach
(gastric bubble) and bowel.
Auscultation:
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Auscultation is listening to internal body sounds to assess normal
sounds and detect abnormal sounds. The sounds produced by heart, lungs,
abdomen and vascular system are commonly assessed by using
stethoscope.
Characteristics of Auscultation sounds:
Pitch:
The number or frequency of sound wave cycles per second. High
frequency results in high pitched sound, where as low frequency produces
low pitched sound.
Intensity:
It is the amplitude of a sound wave. The greater amplitude results the
louder sound where as the lower amplitude results softer sound.
Duration:
It may be long, medium or short.
Quality:
It is the description of a sound’s character such as gurgling, blowing,
whistling or snapping.
Abnormal (Adventitious breath sounds):
Crackles:
1. Crackles in general.
Soft, high pitched, discontinuous popping sounds that occur during
inspiration.
E.g., Chronic bronchitis.
2. Coarse crackles.
Discontinuous popping sounds heard in early inspiration; harsh, moist
sound originating in the large bronchi.
E.g., Pulmonary oedema.
3. Fine crackles.
Discontinuous popping sounds heard in late inspiration; sounds like
hair rubbing together; originates in the alveoli.
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E.g., Chronic bronchitis, emphysema.
Wheezes:
1. Rhonchi.
Deep, low pitched rumpling sounds heard primarily during expiration;
caused by air moving through narrowed tracheobronchial passages.
E.g., COPD, Cystic fibrosis, pneumonia
2. Stridor.
Continuous, musical, high pitched whistle like sounds heard during
inspiration and expiration caused by air passing through narrowed or partially
abstracted air ways; may clear with coughing.
E.g., Croup syndrome, epiglottitis.
Pleural Friction Rub:
Harsh, cracking sound like two pieces of leather being rubbed together.
Heard during inspiration alone or during both inspiration and expiration.
It may subside when patient holds breath.
E.g., Pulmonary infarct, pneumonia.
Abnormal Cardiac Sounds
Gallop.
If the blood filling the ventricle is impeded during diastole, as occurs in
certain disease states, then a temporary vibration may occur in diastole that is
similar to, although usually softer than s1 and s2.
Third heart sound (s3).
Extra heart sound, low pitched, ending in early diastole, similar to sound of
a gallop.
E.g., Left ventricular failure, mitral valve regurgitation.
Fourth heart sound (s4).
Extra heart sound, low pitch ending in late diastole.
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E.g., Left ventricular hypertrophy, pulmonary stenosis.
Cardiac Murmurs.
Turbulent sounds occurring between normal heart sounds.
E.g., Cardiac valve disorder.
Friction Rub.
A harsh, grating sound that can be heard in both systole and diastole is
called friction rub.
E.g., Pericardits.
Guidelines for Performing Physical Assessment
Provide Privacy
Establish Rapport and use good interviewing techniques rather than
working in silence.
Don’t relay on memory – takedown notes for better accuracy
Use the assessment tool available in the organization
Physical Assessment Format
General Appearance
Nourishment : Well nourished/Moderately Nourished/Malnourished
Body Build : Thin/Moderate/Obese
Hygiene and
Grooming : Clean/Neat/Dirty/Unkempt (not combed properly)
Activity : Active/Dull
Health : Healthy/Unhealthy
Posture : Normal posture/Lordosis/Kyphosis/Scoliosis
Movement : Coordinated movement/Tremors/Uncoordinated
movement
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Mental Status :
Consciousness : Conscious/Semiconscious/Unconscious
Behaviour :
Look : Anxious/Depressed/Happy/Pleasant/Sad/Alert
/Tired/Fearful
Attitude : Cooperative/Withdrawn/Hostile
Affect/Mood : Appropriate to situation/Inappropriate to situation
Speech : Clear/Rapid/Slow/Slurring/Stammering/Relevant/
Irrelevant/Aphasia
Orientation : Oriented to time place and person
Vital Signs
Temperature : …………..oC/………….oF
Pulse : ………………beats/minute
Respiration : ………………breaths/minute
Blood pressure : ………………mm of Hg
Height and Weight
Height : ……………….cms
Weight : ……………….kgs
A. Head
Shape : Normal//macrocephalic/ hydrocephalic
/micro cephalic
Scalp : Clean/presence of dandruff/pediculi
Face : Pale/flushed/puffiness/fear/anxiety/enlargement
of parotid Glands/ symmetric
Subjective Symptoms :
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B. Hair : Evenly distributed/thick silky hair/alopecia/very
thin hair/ Brittle hair/excessive
oily/lice/nits/excessive hairness
(Hirsutism)
Texture : Normal/dry
Colour : Black/brown/red/gray etc
Grooming : Not groomed/well groomed
Subjective Symptoms :
C. Eyes
Eye brows : Hair equally distributed/symmetrical/
asymmetrical/scanty etc
Eye lashes : Equally distributed/unequal
Eye lids : Skin intact/edema lesion/etropion
(eversion)/entropion (inversion)/
Redness/lids closed symmetrically
/asymmetrically/ incompletely/painful
/ptosis (drooping of eyelids)
Eye balls : Sunken/protruded
Pupils :
Colour : Black/cloudiness
Size : 3 – 7 mm in diameter
Shape : Round/Oval/Irregular/pinpointed etc
Reaction to light : PERLA->Pupils equally reacting to light and
accommodation
Corneal reflex : Present/absent
Conjunctiva : Pale/normal/yellowish/purulent/conjunctivitis
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Sclera : White/jaundiced (yellow)/reddish etc
Lens : Opaque/transparent
Vision : Client can see objects/myopia (short sight)
hyperopia(Long sight)
Extra ocular muscle test : Normal/nystagmus/cross eye or squint
Subjective Symptoms : No complaints/pain/itching/increased or
decreased production of tears etc
D. Ear
Position : Normal/placed/low set ear
Cerumen : Absent/present
Otorrhoea : Absent/purulent/serous/blood
Subjective Symptoms : No complaints/otalgia/tinnitus/vertigo
Hearing :
Response to Normal voice tone : Normal voice tone audible/not
audible
Watch tick test (2cm – 3cm distance : Able to hear ticking in both ears
(weber negative)/not audible
Turning fork test (weber test) : Sound is heard in both ears/sound
is heard better in impaired ear
Rinne test : Sound heard better in ear with out
a problem
AC>BC(+ve Rinne) BC=AC or
BC>AC
(-ve Rinne conductive hearing loss)
Subjective Symptoms :
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E. Nose
External Nose : Symmetric & symmetric/discharge
(present/ not present)/crusts
Nasal Septum : Midline/deviated
Patency of Nasal Cavity : Air moves freely as the client breaths
through the nares/obstructed
/nasal polyp
Frontal & maxillary sinuses : Normal/painful/render/sinusitis
Smell : Normal/absent(anosmia)
Rhinorrhoea : Absent/watery/purulent/mucoid/epistaxis
etc
Subjective Symptoms :
F. Mouth and Pharynx :
Outer lips : Pink/pale/ability to purse
lips/asymmetry/symmetry/ soft/
moist/smooth texture/or scales
Inner lips : Pink(freckled brown pigmentaion in dark
skinned client)/moist/smooth/
soft/excessive dryness/pale/
leukoplakia(with patches)/ulcerations
Teeth : Smooth/shiny tooth enamel/32
teeth(adult)/missing teeth/yellowish/
stains/ill fitting denture/brown/black
white/dental caries/tooth ache/plague
Gums : Pink/bleedingswelling/pus
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Tongue : Central position/deviated from
center/pink colour/
moist/slightly/rough/thin/whitish
coating/smooth red tongue/dry tongue/
lesions/ulcerations
Movement : Moves freely/no tenderness/restricted
mobility
Palate : Light pink/smooth soft palate/lighter pink
hard palate/discoloration
Uvula : Positioned in midline of soft
palate/deviation to one side from tumor
or trauma/immobility
Tonsils : Smooth/pink/pale/painful/enlarged/not
enlarge
Odour of mouth : Foul smelling
Pharynx : Gag reflex(present/absent) sore
throat/infections/ dysphagia,
odynophagia,
throat pain etc
Voice : Clear/harsh/aphonia/dysphonia
Subjective Symptoms :
G. Neck :
Range of motion : Possible/painful/absent etc
Thyroid gland : Enlarged/not enlarged/removed etc
Trachea : Midline/displaced etc
Lymphnodes : Palpable/not palpable/painful etc
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Jugular Veins : Distended/not distended
H. Chest : Barrel chest/pigeon chest/funnel
chest/transverse diameter is twice
the anterior posterior diameter/
symmetrical/asymmetrical/flat/etc
Expansion of the chest : Symmetry/asymmetry/delayed/shallow
/etc
Palpation :
Tactile fremitus : Symmetry/asymmetry/decreased/
increased
Thoracic excursion : Resonance/hyper resonance
Auscultation :
Apical pulse : ………. beats/mt
Breath sounds : Normal vesicular sound/normal bronchial
sound/ normal broncho vesicular
sound/crackles/stridor/ rhonchi/
wheezing/pleural friction
rub/bronchophony egophony/
whispered pectoriloguy
Cough : Absent/if present(dry/whooping/
productive/ aggravating/factors etc
Sputum : Absent/if present(bad odour/frothy/
mucoid/rusty/
sticky/purulent/green/yellow/blood
stained etc
Subjective Symptoms : No complaints/diaphoresis/breathless/
giddiness/palpitations/chest pain/shoulder
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pain/exercise intolerance etc
Heart : S1, S2 heard/murmur/gallop sounds
I. Breast & Axilla :
Symmetry : Symmetrical/asymmetrical
Areola & nipple : Colour/retracted/inverted/dimpling/erect
etc
Discharge : Absent/milky/yellowish/purulent etc
Lesions/masses : Absent/ulcerations/nodes/swelling/moving/
painful/tender etc
Auxiliary nodes : Not palpable/palpable/moving/painful etc.
Hair distribution : Well distributed/scanty etc
J. Abdomen :
Inspection : Skin rashes/scar/hermia/ascites/flat/abdominal
pulsation seen/linea nigra/umbilicus
clean/infected/ everted etc.
Palpation : Liver/(Palpable/not palpable)/spleen
(palpable/not palpable)/tenderness/soft/masses
etc
Percussion : Presence of gas/presence of fluid/mass
/detected/not detected.
Auscultation : Bowel sounds heard/not heard
Abdominal girth : ……….cms
Inguinal Lymphnodes : Not enlarged/enlarged/movable/painful etc
Appetite : Normal/anorexia/bulimia nervosa/anorexia
nervous
Subjective Symptoms : No complaints/nausea/vomiting/heart burn/
abdominal pain/abdominal cramps/flatulence/
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poly phagia etc.
K. Skin :
Colour : Fair/brown/dark in complexion
Texture : Dryness/wrinkling/excessive moisture/normal
Temperature : Warm/cold and clammy/hot
Lesions : Macules/papules/vesicles/wounds
Turgor : Normal/decreased
Discoloration : Absent/yellowish/cyanosis/pallor/increased
pigmentation
L. Upper extremities :
Symmetry : Symmetrical/asymmetrical
Range of motion : Possible/if impossible (specify)
Peripheral pulses : Brachial, radial pulses (normal rate, rhythm,
volume)
Reflexes : Biceps, triceps, brachio radialis normal if
abnormal...
Oedema/Swelling : Absent/if present (specify area)
Cyanosis : Absent/if present (specify area)
Joints : Stiffness/swelling/tenderness/crepitus etc/absent
Deformity : Absent/if present (specify)
Lower extremities :
Symmetry : Symmetry/asymmetry
Toe nails : Capillary refill …..sec
Range of motion : Possible/not possible (specify)
Peripheral pulses : Dorsalis pedis, posterior tibial artery, popilitial
artery(normal rate, rhythm, volume) if
abnormal…………
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Reflexes : Patellar, ankle jerk, planter (normal) (kneejerk)
if abnormal
Oedema/ Swelling : Absent/ if present (specify area)
Cyanosis : Absent/ if present (specify area)
Joints : Stiffness/ Swelling/ Tenderness/ Crepitus/ etc.
Deformity : Talipes equino varus/ Talipes equino valfum/
bow legs/etc/ absent
Subjective symptoms : No complaints/pain while walking or doing
daily activities/musclecramps/myalgia/problems
with flexion, extension, abduction, adduction,
external and internal rotation etc.
M. Nails
Shape : Convex curve (schamroth’s window test)/
spoon shape (Koilonychia)/ Clubbing
Texture : Smooth/excessive thickness/ excessive thinness/
presence of grooves or furrows/ Beau’s line
(Transverse white lines or grooves on nail may
result from severe injury or illness
Nail bed color : Pink/ cyanosed/ pale etc
Tissues surrounding nails: Intact epidermis/ hang nails/ paronychia
(inflammation of the tissues surrounding a nail)
Capillary refill : (Blanch test) …………..seconds
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N. Genitals and Rectum
Hemorrhoids : Present/ not present
Vaginal Discharge : Present/ not present
Enlargement of prostate gland : Enlarged/ not enlarged
Testis : Descended into scrotum/ undescended
testis
Labia majora & Labia minora : Labia minora is covered by labia majora/
Labia minora is not covered by labia
majora/ ambuigous/ umambiguous
Psychological Assessment
Client’s Perception
It includes the perception of the patient about the referral service
assessment, the gain achieved by the patient from the meeting with the nurse.
Emotional Health
It includes the mental health status stress and coping styles of the
individual.
Social Health
It includes accommodation, finances, relationship, genogram, employment
status, ethnic background, culture, values of the society, traditional beliefs, and
support networks etc.
Physical Health
It includes the assessment general health, illness, previous history, appetite,
weight, sleep pattern, diurinal variations, alcohol, tobacco, drugs etc.
Spiritual Health:
It includes the patient’s belief about the religion, the importance of
religion, in what way it provides a sense of purpose etc.
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Intellectual Health:
It comprises cognitive functioning, hallucinations, delusions,
concentrations, interests, hobbies, etc.
Validating Data
It is a act of making sure that to know which data are actually fact and
which data are questionable.
Validating data helps to avoid
1. Missing pertinent information
2. Misunderstanding Situation
3. Jumping to conclusions or focusing in the wrong direction
CUES : -
The subjective and objective data identified by nurse act as cues.
INFERENCE:-
The cues help to make judgment called inference.
E.g., Subjective data; patient states “I just started taking penicillin for a tooth
abscess”
Objective data; fine rash over trunk.
Cues; the above objective and subjective data’s act as cues.
Inference; the patient is having allergic reaction to penicillin.
Identifying of correct inferences it will influenced by nurse’s
Observational skills.
Nursing knowledge.
Expertise in clinical practice.
Values and beliefs.
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Methods for the validation of cues and inferences
DATA VALIDATION
Identification of Cues
Make Inferences About Cues
Validate Cues and inferences
Guidelines for Validating data
Be aware that data that can be measured with an accurate scale of
measurement can be accepted as factual.
Keep in mind that data that someone else observes to be factual may or
may not be true. When the information is critical, you verified it directly
observing and interviewing the patients.
If data are questionable use the following techniques.
Recheck your own data
Look for temporary factors that may alter the accuracy of your data
Ask someone else ( experts, peer group)
Always double check data that are extremely abnormal
Compare Cues to Knowledge Base of Normal Function
Refer to Textbooks, Journals, Research Reports
Check Consistency of Cues
Clarify Client’s Statements
Seek Consensus With Peers and Colleagues About Inferences
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Compare your subjective & objective data
Organizing Data
Clustering the data into groups of information that will help the nurse to
identify patterns of health or disease.
After validating the patients data the nurse has to organize them into
categories of information that will help to identify patients strengths, and actual
and potential health problems.
Data can be clustered according to
1. Human needs
2. Functional Health Patterns
3. Body System
Organization Assessment Data According to Human Needs (Maslow)
1. Physiological needs.
2. Safety and security needs.
3. Love and belonging needs.
4. Self-esteem needs.
5. Self-actualization needs.
Organization of Assessment Data According to Functional Health Patterns
1. Health-perception-health-management pattern.
2. Nutritional-metabolic pattern.
3. Elimination pattern.
4. Activity-exercise pattern.
5. Cognitive-perceptual pattern.
6. Sleep-rest pattern.
7. Self-perception-self-concept pattern.
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8. Role-relationship pattern.
9. Sexuality-reproductive pattern.
10. Coping-stress-tolerance pattern.
11. Value-belief pattern.
Clustering Data According to Body Systems
1. Cluster together a brief client profile.
2. Respiratory system.
3. Cardiovascular system.
4. Nervous system.
5. Musculoskeletal system.
6. Gastrointestinal system.
7. Genitourinary system.
8. Integumentary system.
Identifying Patterns and Filling in the Gap
Making an initial impression about patterns of information, and gathering
additional data to fill in the gap to describe more clearly what the data mean.
Once we clustered the data into groups of related information we can able
to identify pattern and filling in the gaps of missing data. This can be done by
using puzzle analogy. The nurse can examine many pieces of information and put
some of the pieces of the picture together. Because the nurses have quite a few of
the pieces together, she can now more readily identify key missing pieces. Nurse
can get some initial impressions about the presents of certain patterns when
cluster the data. This initial impressions are often helpful in identifying gaps in
the data collection.
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The nurse should be comprehensive in this process. By this the nurse is
Less likely to
Miss problems.
Identify problems that are not there.
Miss label problems.
Identify interventions that are not likely to work.
More likely to
Identify client strengths.
Identify all the problems.
Label the problems correctly.
Identify appropriate individualized interventions.
Communicating Data
Reporting or recording significant data to expedite treatment and completing the
database.
The data can be communicated through
1. Verbal Communication
2. Written Communication
Verbal communication of significant findings (E.g., Abnormal vital signs,
pain, problems with breathing or circulation) should be given priority over
completing nursing database records.
Guideline for recording the data:
1. Use ink and write or pint legibly.
2. Followed precisely hospital policies and procedures for recording the data.
3. Follow an organized method of recording data.
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4. Document the name of any person contributing to the history other than the
patient.
5. Be clear when you record what you observe.
6. Write patient’s statements using the patient’s own words.
7. Chart whom you notified if you have reported significant data.
8. Chart the most critical data first. (E.g., Vital signs, medications, allergies)
so that if the nurse leave the unit for some reason, the data will be readily
available.
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ExperiencePrevious client care experience.Validation of assessment findings.Observation of assessment techniques.
Attitude PerseveranceFairnessIntegrityConfidenceCreativity
Critical Thinking in Assessment Process
The nurse must apply the principles of critical thinking when performing
client’s assessment. Critical thinking is the active, organized, cognitive process
used to carefully examine the clinical decision making of assessment.
Knowledge Underlying the disease process. Normal growth and development. Normal psychology. Knowledge on physical and social
sciences. Normal assessment findings. Assessment skills. Technical skill. Health promotion.
StandardsStandards of nursing practice.Ethical norms.Standards of measurement
(i) Use evidence based assessment techniques and instruments to collect data.
(ii) Use analytical models and problem solving tools)
Nursing Assessment
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Assessment and clinical nursing judgment
Reassess
Yes No
Assessment of client’s health status Client, family, health care resources comprise database Nurse clarifies inconsistent or unclear information Critical thinking guides and directs line of questioning and
examination to reveal detailed and relevant database
Validate data with other sources
Is additional data needed?
Interpret and analyze meaning of data
Cluster data Group signs and
symptoms Classify and organize
Begin formulation of nursing diagnosis
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