Understanding Nursing Assessment Process

1. Chapter 10The Assessment Process

2. Assessment as a Process • A purposeful, systematic, and dynamic process that is ongoing throughout the nurse’s relationship with individuals in her or his care • Involves the collection, validation, analysis, synthesis, organization, and documentation of client health illness information

3. Assessment • Comprehensive assessment • Includes a complete health history • Screening: recognize symptoms, risk factors, or emotional difficulties • Develops a holistic understanding of the individual’s problems • Focused assessment • A collection of specific information about a particular need • Focused

4. Question • Is this statement true or false? • A comprehensive assessment includes a complete health history Screening – Recognize symptoms, risk factors, or emotional difficulties

5. Answer • False • Rationale: A focused assessment includes a collection of specific information about a particular need.

6. Techniques of Data Collection • Observations • Physical examination • Diagnostic testing • Assessment interviews • May also include family and friends • Collaboration with colleagues

7. Biopsychosocial/Psychiatric/Spiritual Mental Health Nursing Assessment • Types and sources of information • Objective data (also called signs) are directly observable and measurable. • Subjective data (symptoms) are neither directly observable nor measurable.

8. Documentation • Generally speaking, there are two common approaches to documentation. • Source-oriented • Problem-oriented • Information may be entered in the client record in several ways. • Includes fill-in forms, flow sheets, checklists, and narrative notes. • Electronic medical records are becoming more common.

9. Assessment: Biologic Domain • Physical examination • Process by which a clinician collects objective information about the client’s health • Includes height and weight, vital signs, examination of all body systems, and diagnostic testing appropriate to the individual’s age, level of risk, and sex

10. Assessment: Psychological Domain • Responses to mental health problems or consequences. • An important part of assessing the psychological domain is to explore the individual’s experience of illness. • The mental status examination is a systematic assessment of an individual’s appearance, affect, behaviour, and cognitive processes. • Reflects “a snapshot” of the examiner’s observations and impressions at the time of the interview • Evaluates developmental, neurologic, and psychiatric disorders.

11. MMSE • Evaluates • Orientation • Registration • Attention and calculation • Recall • Language

12. Question • Which of the following features is a biologic assessment rather than a psychological assessment? • Thought processes • Cognition and intellectual performance • Attention and concentration • Appetite and nutrition

13. Answer • D. Appetite and nutrition • Rationale: Appetite and nutrition are good indicators of physical health and thus a biologic assessment.

14. Assessment: Psychological Domain (cont.) • Includes manifestations of PMH problems/disorders • Mental status • Stress and coping • Risk assessment

15. Suicide Assessment • Involves garnering specific details regarding: • Suicidal ideation • Threats of suicide • Suicide attempt • To ascertain this information, the nurse asks specific questions about suicidal thoughts.

16. Assaultive or Homicidal Assessment • Includes an evaluation of the level of threat an individual poses to others. • Of particular importance are delusions or hallucinations that involve harming or killing others. • To ascertain this information, the nurse asks specific questions regarding intent to harm someone and plans to harm someone.

17. Social Domain • Assessment includes: • Functional status • Ethnic and cultural assessment • Spiritual assessment

18. Question • Is the following statement true or false? • The phrase “Do you intend to harm someone?” is part of the standard assessment of the likelihood that the patient will attempt suicide.

19. Answer • False • Rationale: The phrase “Do you intend to harm someone?” is part of the assaultive/homicidal assessment.