1. Chapter 16 Nursing Assessment Denise Coffey MSN, RN
The nursing process is the approach nurses use to identify, diagnose, and treat human responses to health and illness. The process is fundamental to how nurses practice.
Students will soon learn that the nursing process is comprised of five steps:
Assessment
Diagnosis
Planning
Implementation
Evaluation
The process is continuous. Nursing assessment helps nurses to form a clear definition of the client's problems, which in turn provides the foundation for planning and implementing nursing interventions and evaluating the outcomes of care.

2. Critical Thinking Approach to Assessment
Nursing assessment
Collection and verification of data
Analysis of data
Database
Consists of client’s perceived needs, health problems, and responses to problems
When performing an assessment, you deliberately and systematically collect data to ascertain the client’s current and past functional status.
Assessment has two stages: first, to collect and verify data from the client (primary source) and from family, health care providers, and medical records (secondary source); second, to analyze the data. The data will be used to develop the nursing diagnosis, identify collaborative problems, and develop an individualized plan of care.
The database can also reveal related experiences, health practices, goals, values, and expectations the client has about the health care system.
Remember, we just talked about critical thinking. You will use these skills while gathering data so you can synthesize the relevant information and use it in a purposeful way.

3. Data Collection Subjective data Objective data Sources of data Client
Family and significant others
Health care team
Medical records
When beginning to assess your clients, you will use cues and inferences to help you deal with all of the data collected. A cue is information that you collect through the use of your senses. An inference is your judgment or interpretation of the cues you just gathered.
Note to faculty member: you will want to discuss the assessment model or tool you utilize at your college or university.
Table 16-1 presents a focused client assessment.
Data can be either subjective or objective. Ask students if they can differentiate between these two.
Subjective data: clients’ verbal descriptions of their own health problems.
Objective data: observations or measurements a health care provider obtains.
Remember that the client is the best source of information. When talking with clients, you will want to remember the concepts we discussed in Chapter 7: Caring in Nursing Practice, as well as in Chapter 9: Culture and Ethnicity in order to create the environment in which clients will feel comfortable discussing their problems with you.

4. Methods of Data Collection
Interview
An organized conversation with the client
Nursing health history
Data about the client’s current level of wellness
The interview has three phases: orientation, working, and termination. While conducting an interview, you need to be prepared so that you collect data you require to plan care.
The orientation phase begins when you first meet the client, introduce yourself, and explain what you are trying to accomplish. You will be required to strictly follow HIPPA regulations. There are summarized in Box It is important to establish trust and confidence with your client at this stage.
During the working phase of the interview you will gather data. You will use appropriate communication strategies that you learned in your speech class. We will further discuss communication in Chapter 24. Remember that some of the most useful techniques will include active listening, paraphrasing, summarizing, and open-ended questions. During the termination stage, you give clients clues that the interview is about to conclude.
During the interview, you will conduct a nursing health history. The history collects information regarding clients’ current level of wellness, as well as a review of body systems, family history, sociocultural history, spiritual health, and mental and emotional reactions.

5. Nursing Health History
Biographical Information
Client expectations
Present illness or health concerns
Health history
Family history
Environmental history
Psychosocial history
Spiritual health
Review of systems
Documentation of findings
Ask students to discuss what type of data each collects.
Biographical data: Age, address, occupations, marital status, health care insurance.
Client expectations: Find out what clients expect to happen to them while seeking treatments for their health.
Present Illness or heath concerns: Determine when the problems began, how severe, intensity, quality, what makes them worse, what makes them better.
Health history: Provides you with information regarding the client’s past history. Has there been a hospitalization? Procedure? Medication uses? Prescription, over the counter, herbal, natural? Use of alcohol, tobacco, caffeine, recreational drugs? Sleeping patterns? Exercise habits? Nutritional habits?
Family history: Blood relative health issues? Recent losses? Religious influences? Relationships?
Environmental history: Home environment? Workplace environment? Exposure to pollutants?
Psychosocial history: Support system? Spouse? Children? Friends? Family members? Coping mechanisms?
Spiritual health: Religion? Religious habits?
Review of systems: A method for collecting data on body systems. We will learn more abut this in Chapters 32 and 33.
Documentation: Each health care facility has forms to use. Refer to your specific health care facility’s documentation forms.

6. Physical Examination Observation of client behavior
Diagnostic and laboratory data
Interpreting assessment data and making nursing judgments
You will learn more about physical assessments when we get to Chapter 33: Health Assessment and Physical Examination.
To accompany the results you obtain from the physical assessment, data can also be obtained from other sources.
By observing clients, you will be able to get more information regarding the physical, developmental, psychological, and social aspects of their life.
Diagnostic and laboratory data will provide you with information needed to develop a plan of care.
Interpreting assessment and data will help you when selecting a nursing diagnosis.
It is important to validate the data. Validation is the comparison of the data you have with data from other sources to determine accuracy.
Data analysis involves recognizing patterns or trends in the clustered data and then comparing them with standards. See Box 16-6 for assistance.

7. Data Documentation The last component of assessment
Legal and professional responsibility
Requires accurate and approved terminology and abbreviations
In Chapter 26 we will discuss documentation more thoroughly.
The client record is a legal document. It can be used in a court of law. It is reviewed by accreditation agencies. It is used by insurance companies to deny or approve patient charges and payments.

8. Concept Mapping
A visual representation that allows nurses to graphically illustrate the connections between a client’s health problems
Allows nurses to obtain a holistic perspective of health care needs
Discussed in Chapter 15, Critical Thinking.
As instructors, we use concept mapping to help students understand relationships between patients’ past and present medical problems. A concept map allows a student to organize and link information about a client. At times, clients will have multiple nursing diagnoses. The concept map allows students to plan interventions that are therapeutic. The map allows students to think critically and promotes clinical decision making.