ASSESSMENT Systematic and continuous collection, organization, validation and documentation of data.

Continuous process carried out during all phases of the nursing process Purpose is to establish a database

Database all the information about the client Ex. Nursing health hx, physical assessment, primary care providers hx, physical examination, lab results, dx test

4 TYPES OF ASSESSMENT a. Initial Assessment b. Problem Focused c. Emergency d. Time Lapsed

STEPS IN ASSESSMENT 1. Data Collection Process of gathering information about a clients health status Systematic and continuous to prevent the omission of significant data and reflects a clients health status 2 TYPES OF DATA a. Subjective (Sx) can be described only by the person experiencing it (Ex. pain, nervousness, vertigo)

b. Objective (Signs) can be observed or measured. (Ex. pallor, diaphoresis, BP, wt, reddish urine) SOURCES OF DATA 1. Primary Client or Pt. 2. Secondary Significant others, patients record, chart, health care team members, relevant literature. Client- best source of data. Unless the client is too ill, young, confused to communicate clearly DATA COLLECTION METHODS 1. OBSERVATION/ OBSERVING Gathering of data by using senses, use of units of measure, physical examination techniques 2. INTERVIEW Planned and purposeful conversation Ex. nursing health history Ex. vision appearance Smell body odor Hearing lung/heart sound, bowel sound Touch temp, pulse rate, palpatory mass

2 APPROACHES a. Directive Interview Question and answer style

Highly structured and needing/elicits specific information Nurse establishes purpose of interview Nurse controls the interview More formal Ex. emergency situation

b. Nondirective Interview Client controls the purpose, subject and pacing Rapport building interview

Rapport trust/understanding between two or more people

TYPES OF INTERVIEW QUESTION

a. Open Ended Invites/let the client discover and explore, eliminate, clarify or illustrate their thoughts and feelings Invites longer answer Specifies broader topic Uses What, How Use in non-directive interview Ex. Kamusta na ang pakiramdam mo ngayon?

B. Close Ended

Answerable by yes or no or small factual answer Use in directive interview Uses When, Where, Who,

c. Neutral Question - answer without direction or pressure by the nurse - Use in non-directive interview

c. d. Leading Question Closed and use in directive interview Give client less opportunity to decide whether the answer is true or not

PLANNING THE INTERVIEW SETTING

a. Time Best time would be when the client is physically comfortable and free of pain When there is minimal interruptions by friends and family members

b. Place Place must be well lighted and well ventilated, minimal or free of noise, movement and distractions

Provide privacy

c. Sitting Arrangement If pt is in bed, sit at 45 degree angle to the bed

d. Distance Distance should be neither too small or too great About 2-3 ft

e. Language Use laymans term Use interpreter or translator If giving written documents, make sure that the client can read and understand the document and knows how to write Nurse must always confirm accurate understanding

STAGES OF AN INTERVIEW a. The Opening Most important part Purpose is to establish rapport and orient the interviewee

b. Body

The patient communicates what he/she thinks, feels, knows and perceives in response to questions from the nurse

c. Closing The nurse terminates the interview when the needed information has been obtained Important for maintaining the rapport and trust and for facilitating

NURSING HEALTH HISTORY All the data obtained from the patient and patients family (significant others) regarding the present and previous illness and hospitalizations Data are obtained during the time that nursing assessment is made Useful in making NCP/plan of care to be given to the patient Purpose: for the nurse to understand the patients reaction to current situation and what are the special considerations that the nurse must know for better patient care.

RELEVANT INFORMATION FOR NURSING HEALTH HISTORY TAKING

1. BIOGRAPHIC DATA Clients name, age, address, sex, birth date, religion, occupation, marital status

2. CHIEF COMPLAIN/ REASON FOR VISIT

Should answer questions such as: Whats troubling you?, Can you tell me the reason why you came to hospital/clinic today?

It should be recorded in clients own word

3. HISTORY OF PRESENT ILLNESS a. When the symptoms started? b. Whether the onset of symptoms was sudden or gradual c. How often the problem occurs? d. Exact location of distress e. Character of complain f. Activity in which the client was involved when the problem occurred g. Phenomena or symptoms associated with the chief complain h. Factors that aggravate or alleviate the problem

4. PAST HISTORY a. Childhood illness (Ex. chickenpox, mumps, measles) or other significant illness b. Childhood Immunization (date and last shot) c. Allergies- foods, medication, etc - type of reaction occurs and how it is started d. Hospitalization for serious illnesses: - reason, date, surgery performed, course of recovery and complication

d. e. Medications currently used prescription and OTC medications

5. FAMILY HISTORY OF ILLNESS Give extra attention to disorders such as: Heart disease Alcoholism PTB HPN cancer Diabetes Arthritis Obesity Allergies

Bleeding Disorder Any mental disorder

6. LIFESTYLE a. Personal Habits/Vices Amount, frequency and duration of substance use (tobacco, alcohol, coffee, cola, tea, and illicit/recreational drugs)

b. Diet Typical diet on a normal day or any special diet Number of meals and snack per day Who cooks/shops for food Ethnically district food patterns Allergies

c. Sleep/Rest Patterns Usual daily sleep/wake times Difficulties in sleeping and remedy

d. Activities of Daily Living (ADLs) Any difficulties experienced in the basic activities such as eating, dressing, elimination and locomotion.

e. Instrumental Activities of Daily living Any difficulties experienced in food preparation, shopping,

transportation

f. Recreation/Hobbies

7. SOCIAL DATA a. Family Relationships/friendship Patients support system in time of stress (Who helps in time of needs?)

b. Ethnic Affiliation - health customs and belief, cultural practices that may affect health care recovery

c. Education History -data about the patients highest education attained and past difficulties with learning

d. Occupational History Current employment status, history of accidents on the job,

occupational hazards

e. Economic Status

f. Home and neighborhood conditions

8. PSYCHOLOGICAL DATA a. Major Stressors experienced and clients perception of them b. Usual coping pattern c. Communication style eye movement, gestures, use of touch and postures

9. PATTERNS OF HEALTH CARE All health care resources the client is currently using and has used in the past. (ex. optha, dentis)