Assessment

Definition

Assessment is the first phase of the nursing process focusing on gathering information or data through history taking and observation including physical examination. The data relate to the client, family, group or community system, present and past medical history etc.Assessment is a continuous process through which you identify the human response patterns or functional health status of your clients (refer Annexure A).

Prerequisites

•  A broad knowledge base
•  Effective communication and interpersonal skills
•  Systematic observation involving inspection, palpation, auscultation and percussion.
•  Accurate interpretation and documentation

Steps:

•  Data Collection
•  Organization of Data
•  Documentation

Collection of Data

1) Identify the client by name, age, gender, address, Dr-in-charge and registration

2) Collect data as current and past health history of illness, family history of illness,

psychosocial patterns.

Example: Identify each of the following as current and historical data


3)Use primary and secondary sources to obtain pertinent data

Example:

Primary Source e.g.          Client

Secondary Source e.g.

Family/significant, other individuals in clients immediate environment
 Other members of health team
 Medical records/reports                      

4) Use different methods of data collection such as observation, physical examination. Four observation techniques are inspection, palpation, auscultation and percussion. Clinical/laboratory examination: Read reports, examination such as testing may be done by the
nurses.

5) Clarify doubts and validate subjective data by secondary sources and objective data.

Organization of Data: Subjective and Objective

You have a comprehensive information about your client. Organize it in a meaningful manner as current and historical subjective and objective data. Often you can use forms meant for documentation. Objective data indicate signs that you can observe and measure. Subjective data include those which the clients or others state, but you can not measure than overtly.



Documentation of Data

You must realize that assessment is incomplete without accurate documentation. Remember that data that are accurately collected, organized and documented. Use recording forms, some essential elements are tested.Characteristics

1) Documents must be easily accessible to different team members

2) Well documented data: Minimize repetitions, prevent gaps and provide baseline information

3) Facilitate delivery of quality care allow the nurse to validate, clarify and update data

4) Assured evaluation of individualized care, assist in demonstrating compliance with the
accepted standards (useful in audits)

5) Create a permanent legal record. May be used in protecting the client, the care providers and the agency.

6) Provide the foundation for nursing research.

Guidelines for Documentation of Client Data

1) Write entries objectively without bias, value judgements or personal opinions. Use question marks to clearly identify subjective statements. For example I think I am losing weight and have lost my appetite.

2) Support data with objective observations. For example Emotional status: depressed, sits alone, rarely initiates, conversation, limited eye contact and cries frequently.

3) Avoid generalization such as normal, good, moderately. Be specific, for example, normal bowel movement is more clearly defined as moves bowel every other day without the use of laxatives

4) Describe findings as thoroughly as possible. For example include details of measurements, depth, colour, odour, drainage while describing clients ulcer.

5) Write or print legibly in non-erasable ink, avoid erasing, crossing out and overwriting the entry.

6) Use correct grammar, 1spelling and abbreviations, avoid slang, labels, short forms.

7) Feed the organized data into the computer as per the policy of agency/unit.