Chapter 12

Assessing

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Four Types of Nursing Assessments

Comprehensive initial
Focused
Emergency
Time-lapsed

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Assessing: The Primary Source of

Information Is the Patient

Copyright 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Comprehensive Initial Assessment

Performed shortly after admittance to hospital
Performed to establish a complete database for problem
identification and care planning

Performed by the nurse to collect data on all aspects of

patients health

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Focused Assessment
May be performed during initial assessment or as routine
ongoing data collection
Performed to gather data about a specific problem
already identified, or to identify new or overlooked
problems
Performed by the nurse to collect data about the specific
problem

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Emergency Assessment
Performed when a physiologic or psychological crisis
presents
Performed to identify life-threatening problems

Performed by the nurse to gather data about the lifethreatening problem

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Time-Lapsed Assessment
Performed to compare a patients current status to
baseline data obtained earlier
Performed to reassess health status and make necessary
revisions in plan of care
Performed by the nurse to collect data about current
health status of patient

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Establishing Assessment Priorities

Health orientation
Developmental stage
Need for nursing

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Medical vs. Nursing Assessments

Medical assessments
Target data pointing to pathologic conditions
Nursing assessments
Focus on the patients response to health problems

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Objective Data vs. Subjective Data

Objective data
Observable and measurable data that can be seen,
heard, or felt by someone other than the person
experiencing them
e.g., elevated temperature, skin moisture, vomiting
Subjective data
Information perceived only by the affected person
e.g., pain experience, feeling dizzy, feeling anxious

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Characteristics of Data
Purposeful
Complete
Factual and accurate
Relevant

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Sources of Data
Patient
Family and significant others
Patient record
Other healthcare professionals
Nursing and other healthcare literature

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The Skill of Nursing Observation

Determines the patients current responses (physical and
emotional)
Determines the patients current ability to manage care

Determines the immediate environment and its safety

Determines the larger environment (hospital or
community)

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Four Phases of a Nursing Interview

Preparatory phase
Introduction
Working phase
Termination

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Purpose of a Nursing Physical Assessment

Appraisal of health status
Identification of health problems
Establishment of a database for nursing intervention

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Successful Interview Techniques

Focus on the patient during the interview
Listen to the patient attentively
Ask about patients main problem first
Pose questions and comments in appropriate manner
Avoid comments and questions that impede
communication

Use silence and touch appropriately

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Type of Questions Used in Interviews

Closed questionselicit specific information
Open-ended questionsallow the patient to verbalize
freely

Reflective questionsencourage patient to elaborate on

thoughts and feelings
Direct questionsvalidate or clarify information

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Collaborating Members of the Healthcare

Team

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Problems Related to Data Collection

Inappropriate organization of the database
Omission of pertinent data
Inclusion of irrelevant or duplicate data, erroneous or
misinterpreted data
Failure to establish rapport and partnership
Recording an interpretation of data rather than observed
behavior
Failure to update the database

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When to Verify Data

When there is a discrepancy between what the person is
saying and what the nurse is observing
When the data lack objectivity

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Validating Inferences
Performing a physical examination using proper
equipment and procedure
Using clarifying statements

Sharing inferences with other team members

Checking findings with research reports

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Documentation of Data
Enter initial database into computer or record in ink on
designated forms the same day patient is admitted
Summarize objective and subjective data in concise,
comprehensive, and easily retrievable manner
Use good grammar and standard medical abbreviations
Whenever possible, use patients own words
Avoid non-specific terms subject to individual
interpretation or definition

Copyright 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question
Tell whether the following statement is true or false.
A nursing assessment duplicates a medical assessment
by focusing on the patients responses to the health
problem.
A. True
B. False

Copyright 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
Answer: B. False
A nursing assessment does not duplicate a medical
assessment, rather it focuses on the patients responses
to the health problem.

Copyright 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question
Which one of the following assessments would be
performed on a patient to gather data about his
previously diagnosed liver cancer?
A. Initial assessment
B. Focused assessment
C. Emergency assessment
D. Time-lapsed assessment

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Answer
Answer: B. Focused assessment
Rationale:
In a focused assessment the nurse gathers data about a
condition that has already been diagnosed.
An initial assessment is performed shortly after the
patient is admitted to a healthcare agency or service.
When a physiologic or psychological crisis presents, the
nurse performs an emergency assessment.
A time-lapsed assessment compares a patients current
status to baseline data obtained earlier.
Copyright 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question
Tell whether the following statement is true or false.
Most healthcare institutions establish a minimum data set
that specifies the information that must be collected from
every patient and uses a structured assessment form to
organize or cluster these data.
A. True
B. False

Copyright 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
Answer: A. True
Most healthcare institutions establish a minimum data set
that specifies the information that must be collected from
every patient and uses a structured assessment form to
organize or cluster these data.

Copyright 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question
Tell whether the following statement is true or false.
A patient rates his pain as a 7 on a pain rating scale.
This rating is considered to be objective data.

A. True
B. False

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Answer
Answer: B. False
A patient rates his pain as a 7 on a pain rating scale.
This rating is considered to be subjective data.

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Question
In which of the following phases of the nursing interview
does the nurse gather all the information needed to form
the subjective database?
A. Preparatory phase
B. Introduction
C. Working phase
D. Termination

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Answer
Answer: C. Working phase
Rationale:
The patient database is obtained in the working phase.
In the preparatory phase, the nurse prepares the patient
and the environment for the interview.
The introduction sets the tone for the remainder of the
interview.
The termination is the conclusion of the interview.

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