Chapter 3

Assessment

Involves gathering data about the patient and their health status.

Diagnosis

using critical-thinking skills, the nurse analyzes the assessment data to identify patterns in the data and draw conclusions about the client’s health status, including strengths, problems, and factors contributing to the problems.

Planning

encompasses identifying goals and outcomes, choosing interventions, and creating nursing care plans

Implementation

involves performing or delegating planned interventions; this is the step in which you carry out the care plan

Evaluation

occurs as the last step of the process and involves making judgments about the client’s progress toward desired health outcomes, the effectiveness of the nursing care plan, and the quality of nursing care in the healthcare setting.

Subjective data

also called covert data or symptoms data, is data the nurse receives via direct communication with the client, family, or community.

objective data

also called overt data or signs data

Are gathered by physical assessment and from laboratory or diagnostic tests.

Can be measured or observed by the nurse or other healthcare providers (e.g., vital signs, urine output).

(May be used to validate (check) or verify (confirm) subjective data. For example, if you think a patient’s report of dietary intake and exercise is inaccurate, you would measure the patient’s weight and ask for a dietary journal.)

Primary data

are data, either subjective or objective in nature, that are obtained directly from the client, either through what the client says or what you observe yourself.

Secondary data

are obtained secondhand; for example, from the medical record or from another caregiver.

Observation

Observation refers to the deliberate use of all of your senses to gather and interpret patient and environmental data. Observing systematically helps you not to miss an assessment area.

Physical Assessment

Physical assessment (or physical examination) produces mostly objective data and makes use of the following techniques: inspection (visual examination), palpation (touch), percussion (tapping a body surface), direct auscultation (listening with the unaided ear), and indirect auscultation (listening with a stethoscope).

interviewing

Interviewing is purposeful, structured communication in which you question the patient in order to gather subjective data for the nursing database.

Comprehensive Assessments

A comprehensive assessment (also called a global assessment, patient database, or nursing database):

Provides holistic information about the client’s overall health status.

Enables you to identify client problems and strengths.

Enhances your sensitivity to a patient’s culture, values, beliefs, and economic situation.

Uses the nursing skills of observation, physical assessment, and interviewing

Focused assessment

A focused assessment is performed to obtain data about an actual, potential, or possible problem that has been identified or is suspected.

It focuses on a particular topic, body part, or functional ability rather than on overall health status

Special Needs Assessments

A special needs assessment is a type of focused assessment that provides in-depth information about a particular area of client functioning.

Nutritional assessment. Perform a nutritional assessment when warranted by the patient’s needs or condition

Pain assessment. Some accrediting agency standards require pain screening for all patients during initial and ongoing assessments.

cultural assessment. Awareness of cultural influences should guide your nursing care. For content included in a cultural assessment

Spiritual health assessment

Spiritual health assessment provides insight into how a client’s spirituality is affected by current life events and health status—far more than merely asking about the client’s religious preference

Psychosocial assessment

A psychosocial assessment typically includes data about family, lifestyle, usual coping patterns, understanding of the current illness, personality style, previous psychiatric disorders, recent stressors, major issues related to the illness, and mental status.

Wellness assessment

A wellness assessment includes data about spiritual health, social support, nutrition, physical fitness, health beliefs, and lifestyle, as well as a life-stress review

Family assessment

A family assessment provides a better understanding of the client’s family-related health values, beliefs, and behaviors.

Community assessment

A community assessment provides information about community demographics; health concerns; environmental risks; and community resources, norms and values, and points of referral.

Functional ability assessment

A functional ability assessment is a specific kind of special needs assessment. Health problems and normal aging changes often bring a decline in functional status; mobility, feeding, bathing, dressing, and continence and toileting can all be impacted. Functional ability is especially important in discharge planning because future rehabilitation and palliative needs are derived from functional ability assessments.

The Joint Commission (2020) requires an initial functional ability assessment “based on the patient’s condition.” These three functional assessment tools are commonly used:

The Karnofsky Performance scale. This tool is used primarily in palliative care settings to assess functional abilities at the end of life. To see the scale

NONDIRECTIVE INTERVIEW

Characteristics- Patient controls subject matter

Nurse clarifies, summarizes, and questions

Uses mostly open-ended questions

Uses- Promote communication

Facilitate thought

Build rapport

Help patient to express feelings

DIRECTIVE INTERVIEW

Characteristics- Nurse controls the topics

Uses mostly closed questions

Uses- Obtain factual, easily categorized information

In emergency situation

Closed question

are those that can be answered with “yes,” “no,” or other short, factual answers. They usually begin with who, when, where, what, do (did, does), and is (are, were).

Open-ended

specify a topic to be explored but phrase it broadly to encourage the patient to elaborate. Use such questions when you want to obtain subjective data. From the answers to the broad questions, you can decide which topics to clarify or follow up with specific and closed questions.

Diagnosis

is the stage in which you analyze the data you gathered during the assessment stage. Using critical-thinking skills, you identify patterns in the data and draw conclusions about the client’s health status, including strengths, problems, and factors contributing to problems.

Health Problem

A health problem is any condition that requires intervention to prevent or treat disease or illness. After you identify a health problem, you must decide how to treat it—independently or in collaboration with other health professionals.

medical diagnosis

A health problem is any condition that requires intervention to prevent or treat disease or illness. After you identify a health problem, you must decide how to treat it—independently or in collaboration with other health professionals.

Significant data(also called cues)

Usually are unhealthy responses.

Draw on your theoretical knowledge (e.g., of anatomy, physiology, psychology).

One cue should alert you to look for others that might be related to it (forming a pattern).

Influence your conclusions about the client’s health status.

Data Gaps

Data gaps are missing pieces of the diagnostic puzzle. If you have a patient with a diagnosis of Constipation, you need to identify factors contributing to the problem. Does the patient’s diet lack fiber? Does the patient postpone defecation? Do they have a history of relying on laxatives? How much fluid do they drink?

Inconsistencies in Data

Inconsistencies occur when subjective and objective data do not align or when a client’s statement of the problem changes in significant ways. Suppose a woman tells you, “I really don’t eat much.” However, she is 5 feet tall and weighs 190 pounds. The client’s statement and the data appear inconsistent.