This is a great introduction and example of a basic assessment and the role of a nurse when conducting a patient assessment.

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Attributed to:
Fundamentals of Nursing, Assessment Part 1, College of Southern Maryland

Assessment


This is the first step in the nursing process and it includes the systematic collection, verification, organization, interpretation, and documentation of your patient's data. This requires the data that is being collected to be correct and complete as it directly impacts the steps in the nursing process that follow.
The purpose of the assessment is to gather data, or information that depicts your patients physical, emotional, psychosocial health. The data collected will help nurses identify the patient's current health status, potential health problems, as well as functional capabilities and dysfunctional abilities as well.

The assessment section actually has several steps:


  • Collecting Data from a variety of sources

  1. **__Subjective Data Collection (symptoms)__** - This is typically information from the client, some times the family's point of view. This includes feelings, perceptions, and concerns. the best way to obtain this information is by conducting an interview with the patient and/or family. A health history of the patient may prove valuable when gathering data as this will help the care staff understand the functional capabilities and emotional health of the patient prior to receiving care in a health care setting.

  2. **__Objective Data Collection (signs)__** - This is observable, measurable information that is collected through standard assessment techniques. This also includes diagnostic and laboratory test results.

Example:

An African-Canadian male, age 81, comes to the emergency room because he cannot move his left arm. The client states, "It happened about an hour ago when my headache got worse. Now I feel nauseated and dizzy." The nurse takes his vital signs: BP 168/98, P100, R28, T37, and observes that he cannot move his left arm and his face is flushed and he is diaphoretic.

Subjective Data - headache, nausea, dizziness

Objective Data - All the Vital Signs, the fact he is unable to move his left arm, flushed face, appears diaphoretic


  • Validating the data

Objective data may add or validate subjective data. A critical step in data collection, validation prevents misunderstandings and conclusions. This is a very important step, especially if sources are considered unreliable. If a client is confused and/or unable to communicate, or if two sources of information are giving conflicting thoughts, it is likely necessary for the nurse to seek more information before making a clinical judgement. The nurse needs to validate the findings in order to move onto the next step of the process.

  • Organizing the data

Data has to be organized so that it is useful to the health care team members. This information can be organized into categories or clustered into related areas. For example, cognitive assessment data would relate to the ability to follow direction, whereas a cardiac assessment would be related to a patient experiencing difficulty breathing. A patient's ability to walk with an assistive device versus walking independently or being at risk for a fall would all be related under a MOBILITY category. Data can also be clustered into body systems, or functional health patterns, theory of self care

  • Interpreting the data

Once the data has been collected the nurse can look for connections or gaps in the data, as well as recognize any patterns in response and behavior. When information is clustered or organized the nurse is able to distinguish between relevant and irrelevant data and identify patterns of cause and effect.

  • Documenting the data

Documentation decides the quality of care that will be provided to your patient. It is essential that based on the collected data that the nurse is able to make a judgement about which data must be reported immediately, versus what information is not in immediate need of attention. Documentation is a form of communication and it is very important that nurses communicate the needs of the patients, and the nursing care that was implemented to the oncoming staff at shift change. IF it was not documented, it was never done. This is the basic rule of thumb in nursing documentation, no professional is to assume that a treatment was conducted if it is not documented in a patient's chart as having been completed.