ASSESSMENT

 First step in determining

health status
 Gather information
 Gather all the “puzzle
pieces” to put together a
clear picture of health status
 Entire plan is based on data
collected
 Data needs to be complete
and accurate, make sense of
patterns
 Steps in the assessment
phase of the nursing
process:
Establish a data base by
a. Taking the client’s vital signs
b. Performing a head to toe
examination
c. Taking a complete nursing
history
d. Reviewing the client’s chart &
the literature
e. Consult with the client, his
significant others
 4 Types of Assessment
1. Initial Assessment
 also known as triage, helps to determine the nature of
the problem and prepares the way for the ensuing
assessment stages.
 Components may include obtaining a patient's medical
history or putting him through a physical exam, or
preparing a psychosocial assessment for a mental
health patient.
 Other components may include obtaining a patient's
vital signs and taking subjective statements from the
patient, as well as double-checking the subjective
symptoms with the objective signs of the condition.
 4 Types of Assessment
2. Focused Assessment
 The focused assessment is the stage in which the problem
is exposed and treated.
 Due to the importance of vital signs and their ever-
changing nature, they are continuously monitored during
all parts of the assessment. Depending on the malady,
initial treatment for pain and long-term treatment for the
root cause of the malady is administered and monitored.
 Part of the goal of the focused assessment is to diagnose
and treat the patient in order to stabilize her condition.
Focused assessments may also include X-rays or other
types of tests.
 4 Types of Assessment
3. Time-Lapsed Assessment
 Once treatment has been implemented, a
time-lapsed assessment must be conducted to
ensure that the patient is recovering from his
malady and his condition has stabilized.
 During the time-lapsed assessment, the
current status of the patient is compared to
the previous baseline during and prior to
treatment.
 4 Types of Assessment
4. Emergency Assessments
 During emergency procedures, a nurse is focused on rapidly
identifying the root causes of concern for the patient and
assessing the airway, breathing and circulation (ABCs) of
the patient.
 Once the ABCs are stabilized, the emergency assessment
may turn into an initial or focused assessment, depending
on the situation. If the nurse is not in a health care setting,
emergency assessments must also include an assessment
for scene safety so that no other individuals, including the
nurse himself, are hurt during the rescue and emergency
response process.

 PROCESS OF DATA
COLLECTION
 Physiologic: body systems approach that is sometimes
referred to as a medical model or a head-to-toe
assessment.
 Functional health patterns: identification of
behavioural health patterns over time which facilitates
recognition of functional and dysfunctional patterns.
 Needs models based on Maslow’s hierarchy of needs.
For a review of Maslow’s hierarchy click on the link
below.
 Prescribed agency driven formats which are generally
an adaptation or hybrid of various models.
 TYPES OF DATA
• S – Subjective -
What the patient
tells you;
Subjective =
Statements; “I’m
itching”
• O – Objective –
Detectable by an
observer or can
be tested; O =
Objective
 SOURCES OF DATA
 Patient – primary source; best source of
information
 Family and Significant Others - secondary
source
 Health Care Team
 Medical Records
 EFFECTIVE
COMMUNICATION DURING
INTERVIEW WITH A PATIENT
Courtesy
Comfort
Connection
confirmation
 PHASES OF INTERVIEW
Orientation and Setting of the Agenda
Working Phase
Terminating phase
COMPONENTS OF NURSING
HEALTH HISTORY
A. Biographical Information
B. Chief Concern/complaint
C. History of Present Illness or Health Concerns
D. Health History (Past)
E. Family History
F. Psychosocial History
G. Spiritual Health
H. Review of Systems