NURSING ASESSMENT

NS. NI MD ARIES MINARTI, S.KEP., M.Ng

Nursing Assessment
• Gathering Information About The Health
Status Of A Person
• Identify Concerns And Needs That Can Be
Treated Or Managed By Nursing Care.
• Look, listen, touch,
– to make an informed decision about care.
 Types of Assessment
• Initial
• Focused
• Time Lapsed or ongoing assessment
• Emergency
 Initial Assessment
Initial assessment is conducted to all patients registered or inputted in
the hospital for treatment/care as inpatient or outpatient.
Purpose :
To establish a complete data base for problem identification , refernce
and future comparison

Initial assessment is conducted when patient arrives for the first time in
inpatient department (IPD), outpatient department (OPD), and
emergency department (ED)).

Initial assessment and reassessment is conduction by the attending

physician who has license in in accordance with his/her clinical privilege
 Focused Assessment
• Ongoing process integrated with nursing care
Purpose :
To determine the status of a specific problem
identified in an earlier assessment and the
identify new or overlooked problem
EX : Hourly assessment of client’s fluid intake
and output chart
 Time-lapsed assessment or Ongoing
assessment
Time Lapsed reassessment, another type
of assessment, takes place after the initial
assessment to evaluate any changes in the
clients functional health. Nurse perform time-
lapsed reassessment when substantial periods
of time have elapsed between assessments
(e.g., periodic output patient clinic visits, home
health visits, health and development
screenings)
 Emergency assessment
Emergency assessment takes place in life-
threatening situations in which the preservation
of life is the top priority. Time is of the essence
rapid identification of and intervention for the
client’s health problem. Often the client’s
difficulties involve airway, breathing and
circulatory problems (the ABCs).
Emergency assessment focuses on few essential
health patterns and is not comprehensive.
 Components of Health History
1-Biographical Data: This includes
Full name
Address and telephone numbers (client's permanent
contact of client)
Birth date and birth place.
Sex
Religion and race.
Marital status.
Social security number.
Occupation (usual and present)
Source of referral.
Usual source of healthcare.
Source and reliability of information.
Date of interview.
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 2- Chief Complaint: “Reason For
Hospitalization”.

Examples of chief complaints:

Chest pain for 3 days.
Swollen ankles for 2 weeks.
Fever and headache for 24 hours.
Physical examination needed for camp.

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 3-History of present illness

• Reason for admission/chief complaint

• Demographic information
• History of present illness
• Family history
• Other history
– Medical: diabetes, heart disease, renal disease
– Surgical history

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 Component of Present Illness
Introduction: "client's summary and usual
health".
Investigation of symptoms: "onset, date,
gradual or sudden, duration, frequency,
location, quality, and alleviating or
aggravating factors".
Negative information.
Relevant family information.
Disability "affected the client's total life".
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 4- Past Health History:
The purpose: (to identify all major past
health problems of the client)
This includes:
Childhood illness e.g. history of
rheumatic fever.

History of accidents and disabling injuries

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 Past Health History. Cont…

History of hospitalization (time of

admission, date, admitting complaint,
discharge diagnosis and follow up care.
History of operations "how and why this
done"
History of immunizations and allergies.
Physical examinations and diagnostic
tests.
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 5-Family History
The purpose: to learn about the general
health of the client's blood relatives,
spouse, and children and to identify any
illness of environmental genetic, or
familiar nature that might have
implications for the client's health
problems.

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 Family History. Cont…

Family history of communicable diseases.

Heredity factors associated with causes of
some diseases.
Strong family history of certain problems.
Health of family members "maternal, parents,
siblings, aunts, uncles…etc.".
Cause of death of the family members
"immediate and extended family".
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 7- Current Health Information
The purpose is to record major, current,
health related information.
Allergies: environmental, ingestion, drug,
other.
Habits "alcohol, tobacco, drug, caffeine"
Medications taken regularly "by doctor or self
prescription
Exercise patterns.
Sleep patterns (daily routine).
The pattern life (sedentary or active)
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 8- Psychosocial History:

Includes :
How client and his family cope with
disease or stress, and how they responses
to illness and health.
You can assess if there is psychological
or social problem and if it affects general
health of the client.

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 9- Review of Systems (ROS)

Collection of data about the past and the

present of each of the client systems.
(Review of the client’s physical, sociologic,
and psychological health status may
identify hidden problems and provides an
opportunity to indicate client strength and
liabilities

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 Physical Systems
Which includes assessment of:-
General review of skin, hair, head, face, eyes, ears,
nose, sinuses, mouth, throat, neck nodes and breasts.
Assessment of respiratory and cardiovascular system.
Assessment of gastrointestinal system.
Assessment of urinary system.
Assessment of genital system.
Assessment of extremities and musculoskeletal
system.
Assessment of endocrine system.
Assessment of heamatoboitic system.
Assessment of social system.
Assessment of psychological system.
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 Methods of Assessment

1. Observing

2. Interviewing

3. Examining
 Assessment Techniques

• Inspection

• Palpation

• Percussion

• Auscultation
 Inspection
• Visual examination - looking
• Color, shape, size, symmetry, position and
movement
• Good lighting is very important
 Palpation
• Assessment through touch
• Temperature, moisture, texture, tenderness,
masses, and edema
• May be light or deep, one hand or two
• Make sure your hands are clean and
fingernails short!
 Percussion
• Short, sharp strikes to the body surface to
produce palpable vibrations and sounds
• Maybe direct (one hand) or indirect (two
hands)
• Can detect size, shape, density and location of
structures
 Auscultation
• Listening to the sounds in the body (usually
with a stethoscope)
• Used to listen to lung sounds, heart sounds
and abdominal sounds
• Keep your stethoscope clean!
 Physical Assesment

• Head-to-toe Assessment

• Body Systems Assesment

 HEENT
• Head, Eyes, Ears, Nose, Throat
• Look at distribution of hair. Are there any
lumps on the head? Discolorations?
• Is head normal size? Upright? Are the facial
structures symmetrical in shape?
• Basically a Cranial nerve assessment
• You do not need to check each cranial nerve at
this point, but be aware of what they are and
how to assess them.
 HEENT
• Does the mouth droop?
• Talk to the patient. Do all the facial muscles move
together?
• Can the person see and hear well?
• Pupils equal, round and reactive to light and
accommodation.
• What does this mean?
• Check the eye muscle function. Have the patient
follow your finger to all eight positions.
• Inspect the ear and assess hearing by talking to the
patient
 Cranial Nerves
• examine sensation and movement of the face:
the facial nerve--CN VII and the trigeminal
nerve--CN V
• List the function of each cranial nerve. Which
ones are used for swallowing?
 Other HEENT
• Check the nose for abnormalities
• If warranted, palpate the sinuses for tenderness
• Look at mouth and neck. Take a look at the tongue.
Are there white patches? Red patches?
• Check range of motion for the neck (gently!).
• Look at the neck for jugular vein distention. This
could indicate a heart problem.
 Other HEENT
• Where are these structures?
– Lymph nodes
– Jugular veins
– Carotid arteries
– Trachea
– Trapezius and sternocleidomastoid
 Head and Neck
• size, symmetry, position and movement of
head
• temporomandibular joint
 Skin
• Inspection
– Intact, free of lesions
– Pink toned or underlying healthy glow
• Palpation
– Warm, cold, moist, dry
– Lesion: Hard, firm, feels like fluid
– Movable, fixed, attached to underlying structures
 Skin Color
• cyanosis (central, peripheral, circumoral),
• jaundice,
• pink tone, glowing, ashen
• pallor,
• Erythema
• Turgor
• Moisture
• Temperature
 Assessment Process

1. Collect Data; Subjective and Objective

2. Organize Data; group or cluster of data
3. Validate Data (double-checking); complete,
factual, accurate
4. Documenting Data; recorded in factual
manner and not interpreted by the nurse
 Sources of data

• Primary

• Secondary
 That-clauses
Verb + that-clause
Verbs commonly followed by that include
reporting verbs (say, tell, admit, etc.) and
mental process verbs (believe, think, know,
hope, etc.)
 Examples
• They said that four million workers stayed at
home to protest against the tax.
• The survey indicated that 28 per cent would
prefer to buy a house through a building
society than through a bank.
• He knew that something bad had happened.
• Do you think that they forgot to pay or that
they stole it?
Adjective + that-clause
We use be + adjective + that-clause to express
opinions and feelings. Some adjectives
commonly used in this way are sure, certain,
right, important, afraid, pleased, sorry,
surprised, worried.
 Examples
• It’s important (that) we look at the problem in
more detail.
• I’m sure (that) you’ll know a lot of people
there.
• They were afraid (that) we were going to be
late.
Noun + that-clause
We use a noun + that-clause to express opinions
and feelings, often about certainty and
possibility. We also use that with reporting
nouns. Some nouns commonly used in this way
are belief, fact, hope, idea, possibility,
suggestion, statement, claim, comment,
argument
 Examples
• He is also having intensive treatment in
the hope that he will be able to train on
Friday.
• Dutch police are investigating
the possibility that a bomb was planted on
the jet.