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Nursing Process: Nursing
Assessment
George Ann Daniels, MS, RN
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Assessment
Continuous and systematic collection,validation, and communication of client
data .(Harrington, 1996)
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Assessment
Purpose: Collect, validate and organize data
about a clients state of wellness, functional
ability, physical status, strengths, and
responses to actual and potential health
problems.
Initial, focused, time-lapsed and emergencyassessment are done depending on the
circumstances
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Essential pre-assessment
activities Choose a framework for assessment and
documentation
Gordons functional health patterns
Control the environment
Work on assessment skills
Observation
Interviewing
Physical exam
Intuitions
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Types of Data
Subjective: facts presented by the client that
show his/her perception
Objective: facts that are observable and
measurable by the nurse, involves use of the
senses
Seeing
Hearing
Smelling
Touching
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Cues
A word used to describe the individual
pieces of data or hints about what is going
on with the client
Also called assessment findings
Cues are analyzed to arrive at appropriate
NDX
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Sources of Data
Primary: from the client, considered the
most reliable if the client is deemed a good
historian
Nursing judgment
Secondary: significant others, the medical
or health record, lab tests, diagnosticprocedures, meds, past medical HX, other
health team members, and literature review
Data needs to be validated
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Organization of Data
Need to use an organized assessment
framework to help cluster assessment data
(cues)into meaningful groups
RSU uses Gordons Functional Health
Patterns
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Health Perception-Health
Management Clients awareness of personal health and
well-being; health practices; understanding
of how health practices contribute to health
status
To assess this pattern, focus on a general
survey of the clients health status and theirusual health behaviors
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Nutritional-Metabolic Pattern
Patterns of food and fluid intake,
relationship of intake to metabolic needs;
skin assessment, fluid volume,thermoregulation
To assess this pattern, focus on eating
habits, appraisal of appetite, weight loss orgain, changes in skin, hair,or nails.
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Elimination Pattern
Patterns of excretory function (Bowel,
Bladder,and Skin), and client perception of
same
Assess usual bowel and bladder elimination
habits,laxative use, excretory function of
skin (e.g. excessive perspiration)
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Activity -Exercise
Patterns of exercise, activity, leisure
recreations, and ADL; factors that interfere
with desired or expected individual pattern
Assess mobility status, exercise routine,
leisure activities, cardiovascular status
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Sleep- Rest pattern
Patterns of sleep and rest-relaxation periods
during 24 hour day. As well as quality and
quantity
Assess regular sleep habits and routine
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Cognitive-Perceptual Pattern
Adequacy of sensory modes, such as vision,
hearing taste, touch, smell, pain perception,
cognitive functional activities
Assess changes in cognitive function,
ability to hear, see, and speak, presence of
pain, numbness, or other sensations
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Self-perception- Self-concept
Pattern Individuals attitudes about self, perception
of abilities, body image, identity, general
sense of worth and emotional patterns
Assess descriptions of self, physical
appearance, effects of illness, major life
accomplishments and changes
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Role- Relationship Pattern
Client's perception of major roles and
responsibilities in current life situation
Assess client's perceptions of key
relationships, observation of interactions
with others
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Sexuality-Reproductive Pattern
Client's perceived satisfaction or
dissatisfaction with sexuality.
Reproductive stage and pattern
Assess clients appraisal of his or her sexual
role and sexual health.
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Coping-Stress Tolerance Pattern
General coping pattern, stress tolerance and
management, support systems, and
perceived ability to control and managesituations
Assess current stress level, coping ability,
ability to endure life stressors, physiologicresponses to stress
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Value- Belief Pattern
Values, goals, or beliefs that guide choices
or decisions.
Assess identification of valued people and
possessions, source of support, religious
practices
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Measurement Criteria for ANA
Standard I: Assessment: The nurse collects
client health data
Data collection involves client, significant
others, and healthcare providers when
appropriate
The priority of data collection activities isdetermined by the clients immediate condition
or needs
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Pertinent data are collected using
appropriate assessment techniques and
instruments
Relevant data are documented in a
retrievable form
The data collection process is systematic
and ongoing
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