Assessment is the systematic and continuous collection, verification, and communication of client data. The assessment includes health history and physical assessment.
Assessment Observation of the patient + Interview of patient and family + Examination of the patient + Review of the medical record.
TYPES
Initial assessment:
Its performed within a specified time on admission, e.g., nursing admission assessment.
Problem-focused :
This determines the status of a specific problem identified in an earlier assessment, e.g., problem on urination-assess on fluid intake and urine output hourly.
Emergency assessment:
Rapid examination is done during any physiologic/ psychologic crisis of the client to identify life-threatening problems, e.g., examination of a client’s airway, breathing status, and circulation after a cardiac arrest.
COLLECTION OF DATA
It means gathering information about the client.
TYPES OF DATA
The nurse collects data about the health status of the client. The data is subjective and objective.
Subjective Data:
Also referred to as Symptom/Covert data ask from the patients. Whatever the patient feels.
Objective Data:
Also referred to as Sign/Overt data. Objective data can be seen or measured by Doctors/Nurses.
HISTORY COLLECTION
Biographic data:
Name, address, age, sex, marital status, occupation, religion. Reason for visit/Chief complaint: Primary reason why client seeks consultation or hospitalization.
History of present illness includes Usual health status, chronological history, family history, and disability examinations.
Past health history:
Includes all previous immunizations, and experiences with illness. > Family history: Reveals risk factors for certain diseases (Diabetes, hypertension, cancer, mental illness).
Review of systems:
A complete review of all end-to-end communications is conducted.
Lifestyle:
Include personal daily routine and habits, diets, sleep or rest patterns, activities of daily living, and recreation.
Social data:
Include family conditions and relationships, ethnic and educational background, economic status, home and neighborhood conditions, etc.
Psychological data:
Information about the client’s emotional state.
The pattern of health care:
Includes all health care resources like Hospitals, health centers, clinics, and family doctors.
PHYSICAL EXAMINATION
A nursing Examination includes a physical examination. The techniques used may include Inspection, Palpation, Percussion, and Auscultation.
Inspection:
Inspection is the visual examination of the client. This may include noting the patient’s respiratory effort, observing skin color, or measuring a wound.
Palpation:
Palpation is defined as the sense of touch to assess various parts of the body. The hands, especially the fingertips are used to assess skin temperature, check pulses, texture, moisture, masses, tenderness, pain, swelling, firmness, and vibration.
Percussion:
Percussion is the striking of the body surface with shout, sharp strokes to produce palpable vibrations and characteristic sounds. It is used to determine the location, size, shape, and density of underlying structures; to detect the presence of air or fluid in a body space; and to elicit tenderness or a dull sound heard over a fluid-filled area. A flat sound is heard over a solid area. Tympany is a drum-like sound heard over the air, such as gas in the stomach. Resonance is a hollow sound heard over air-filled lung tissue.
Auscultation:
Auscultation is usually done with a stethoscope. Auscultation is the process of listening to sounds produced inside the human body.
HEAD-TO-FOOT EXAMINATION
- General examination
- Physical body assessment
- Vital sign assessment
- Inspection
- Ophthalmoscopic examination
- Otoscopic examination
- Lung assessment
- Heart assessment
- Gastric examination
- Breast palpation
- Hepatic liver palpation
- Pelvic organ examination by palpation
- Rectal examination
NURSE’S ROLE IN EXAMINATION OF PATIENTS
Nursing Role :
- Prepare suitable environment
- Preparation of equipment
- Patient preparation includes: Positioning Psychological
- Record and report of findings
Some of the data collection and and study which occur in the hospital are click here to learn and see the examples and assessment and data collections
