nursing, health, assessment, carmela domocmat, steps in health assessment, steps in assessing

1. Steps of Health Assessment

2. Five key phases of assessment
1. Collecting data
2. Validating (verifying) data
3. Organizing data
4. Analyze the data
5. Identifying patterns/testing first
impressions
6. Reporting and recording data
Maria Carmela L. Domocmat, RN, MSN

3. Collecting data
• Subjective and Objective data
– Aids critical thinking because each
complements and clarifies the other.
– Subjective data – what the person
states verbally or in writing
– Objective data – what you observe
– S – S: Subjective = Stated
– O – O: Objective = Observed
Maria Carmela L. Domocmat, RN, MSN

4. Collecting subjective data
subjective data are data that are elicited
and verified only by the client
obtained through interviewing
Maria Carmela L. Domocmat, RN, MSN

5. Includes Complete Health
History
Biographical data Family health history
Reasons for seeking Review of body
health care systems (especially
History of Present for current health
Health concerns problems)
Past health history Lifestyle and health
practices profile
Developmental level
Maria Carmela L. Domocmat, RN, MSN

6. Collecting objective data
• Data directly observed or detectable by the
examiner or can be tested by using an accepted
standard
Maria Carmela L. Domocmat, RN, MSN

7. Collecting objective data
• Data include:
physical characteristics
body functions
appearance
behavior
measurement
results of laboratory testing
Maria Carmela L. Domocmat, RN, MSN

8. • Objective data are sometimes called
signs,
• Subjective data are sometimes called
symptoms.
Maria Carmela L. Domocmat, RN, MSN

9. • Subjective data:
– States, “I feel like my heart is racing.”
• Objective data:
– Pulse 150 beats, regular, and strong.
Maria Carmela L. Domocmat, RN, MSN

10. • The objective data support the subjective
data: what you observe confirms what the
person is stating.
Maria Carmela L. Domocmat, RN, MSN

11. • The subjective and objective data you
identify act as cues.
• Cues are data that prompt you to get an initial
impression about patterns of health or illness.
• The cues may lead you to infer (suspect).
• Inference – the conclusion drawn about the cue: it
is how you interpret or perceive a cue.
Maria Carmela L. Domocmat, RN, MSN

12. • Cues – subjective or objective data
observed by the nurse; it is what the client
says, or what the nurse can see, hear,
feel, smell or measure.
Maria Carmela L. Domocmat, RN, MSN

13. • Inferences – the nurse interpretation or
conclusion based on the cues.
• Example: red, swollen wound = infected
wound; Dry skin = dehydrated
Maria Carmela L. Domocmat, RN, MSN

14. ACTIVITY
Maria Carmela L. Domocmat, RN, MSN

15. Subjective and Objective Data
• Read the following case studies and
answer the subsequent questions.
Maria Carmela L. Domocmat, RN, MSN

16. Case study 1
Mr. Michaels is 51 years old. He was admitted two days ago with chest
pain. His physician has ordered the following studies: electrocardiogram,
chest x-ray, and complete blood studies including a blood sugar. These
studies were just posted on the chart. When you talk with him, he
states, “I feel much better today – no more pain. It is a relief to get rid
of the discomfort.” You think he appears a little tired or weary – he
seems to be talking slowly and sighs more often than you would think
is necessary. When his wife comes to see him, she is cheerful with him,
but confides in you he seems depressed or something. His vital signs
are: T. 98.8, P: 74 and regular, R: 22; BP: 140/90.
Maria Carmela L. Domocmat, RN, MSN

17. 1. List the subjective data noted for Mr.
Michaels
2. List the objective data noted for Mr.
Michaels
Maria Carmela L. Domocmat, RN, MSN

18. The subjective data noted for Mr.
Michaels
Patient states:
◦ “No pain today”
◦ Pain relieved - “feels relieved”
◦ Wife states he seems depressed.
Maria Carmela L. Domocmat, RN, MSN

19. The objective data noted for Mr. Michaels
◦ Lab results
◦ Talking slowly
◦ Sighs
◦ Vital signs
◦ Appears tired, weary
◦ Patient’s age
Maria Carmela L. Domocmat, RN, MSN

20. Case Study 2
Mrs. Rochester is a 33 year old mother of two young children. She is
admitted with the medical diagnosis of diabetes. Today you enter room,
and she states, “The doctor says I have diabetes. I can’t see how I could
have diabetes. No one in my family has diabetes. I feel fine—I don’t see
how I can make myself change the way I eat. Dieting drives me crazy –
that’s why I weighed 190 pounds when you weighed me. On further
questioning, she admits she has been feeling unusually tired lately, and
she does seem to have to urinate more than usual. You check her chart
and note her fasting blood sugar was elevated at 144. Her vital signs
are: T: 98.10 F; P: 88 and regular; R: 24; BP: 144/88.
Maria Carmela L. Domocmat, RN, MSN

21. 1. List the subjective data noted for Mrs.
Rochester.
2. List the objective data noted for Mrs.
Rochester.
Maria Carmela L. Domocmat, RN, MSN

22. The subjective data noted for Mrs.
Rochester.
◦ Patient states:
◦ “I can’t believe I have diabetes.”
◦ “I don’t think I can change eating habits.”
◦ Verbalization of feeling tired lately
◦ Increased urination is offered as a concern
Maria Carmela L. Domocmat, RN, MSN

23. The objective data noted for Mrs.
Rochester.
◦ 33 years old
◦ Mother of 2
◦ Weight
◦ Diagnosis of diabetes
◦ Blood sugar
◦ Vital signs
Maria Carmela L. Domocmat, RN, MSN

24. Identify the client data as objective
or subjective.
Mrs. Jones says,” I can’t Mrs. Jones is breathing rapidly.
sleep.”
Client has a pulse of 104. The client states he has a hip
fracture.
Client states, “I am cold.” Surgical dressing is dry.
Client says she cannot void.
Client is coughing.
Client walks with a limp. Wheezes are auscultated.
Maria Carmela L. Domocmat, RN, MSN

25. Identify the client data as objective
or subjective.
__S__ Mrs. Jones says,” I can’t __O__ Mrs. Jones is breathing rapidly.
sleep.”
__O__ Client has a pulse of 104. __S__ The client states he has a hip
fracture.
__S__ Client states, “I am cold.” __O__ Surgical dressing is dry.
__S__ Client says she cannot void.
__O__ Client is coughing.
__O__ Client walks with a limp. __O__ Wheezes are auscultated.
Maria Carmela L. Domocmat, RN, MSN

26. Validation of data
• a crucial part of assessment that often
occurs along with collection of subjective
and objective data
Maria Carmela L. Domocmat, RN, MSN

27. Validation of data
• the act of “double-checking” or verifying
data to confirm that it is accurate and
complete.
Maria Carmela L. Domocmat, RN, MSN

28. Purposes of data validation:
• ensure that data collection is complete
• ensure that objective and subjective data
agree
• obtain additional data that may have been
overlooked
• avoid jumping to conclusion
• differentiate cues and inferences
Maria Carmela L. Domocmat, RN, MSN

29. Validating (verifying) data
Maria Carmela L. Domocmat, RN, MSN

30. Validating (verifying) data
• Helps avoid:
– Making assumptions
– Missing pertinent information
– Misunderstanding situations
– Jumping to conclusions or focusing in the
wrong direction
– Making errors in problem identification
Maria Carmela L. Domocmat, RN, MSN

31. • Guidelines:
– Data that can be measured accurately can be
accepted as factual (e.g. height, weight,
laboratory study results
– Data that someone else observes (indirect
data) may or may not be true. When the
information is critical, verify it by directly
observing and interviewing the patient
yourself.
Maria Carmela L. Domocmat, RN, MSN

32. – Validate questionable information by using the
following techniques, as appropriate:
• Double-check that your equipment is working
correctly
• Recheck your own data (e.g. take a client’s BP in
the opposite arm or 10 min later)
• Look for factors that may alter accuracy
• Ask someone else, preferably an expert, to collect
the same data
Maria Carmela L. Domocmat, RN, MSN

33. • Double-check information that is extremely
abnormal or inconsistent with patient cues
(e.g. use two scale to check an infant who
appears too much heavier or lighter, or
repeat extremely high or low lab result)
• Compare subjective and objective data to
see if what the person is stating is
congruent with what you observe
Maria Carmela L. Domocmat, RN, MSN

34. • Clarify statements and verify your
inferences (e.g. “To me, you look tired”)
• Compare your impressions with those of
other key members of the health care
team.
Maria Carmela L. Domocmat, RN, MSN

35. Organizing (clustering) data
Maria Carmela L. Domocmat, RN, MSN

36. Organizing (clustering) data
• Clustering the data together is a critical-
thinking principle that enhances your
ability to get a clear picture of the client’s
health status.
Maria Carmela L. Domocmat, RN, MSN

37. • Ways to cluster data:
– Clustering data according to a nursing model
– helps to identify nursing diagnoses and
problems
• Henderson’s Components of Nursing Care
• Gordon’s Functional Health Patterns
• NANDA’s human response patterns
• Maslow’s theories
• -
Maria Carmela L. Domocmat, RN, MSN

38. • Ways to cluster data:
• Clustering data according to body systems
– helps to identify data that may indicate
medical problems
Maria Carmela L. Domocmat, RN, MSN

39. • Note: It is important to do both in order to
facilitate recognition of both possible
nursing problems and medical problems.
Maria Carmela L. Domocmat, RN, MSN

40. • If you cluster data according to body
system only, you are likely to miss key
information that helps you identify nursing
diagnoses.
Maria Carmela L. Domocmat, RN, MSN

41. • If you cluster data according to a nursing
model only, you may group your data in
such a way that medical problems may not
be obvious.
Maria Carmela L. Domocmat, RN, MSN

42. • Assessment tools
– Gordon’s Functional Health Patterns
– Katz Index of Independence
– Barthel Index
– Newborn – APGAR Scoring System
– Infants and Children – MMDST
Maria Carmela L. Domocmat, RN, MSN

43. Gordon’s Functional Health
Patterns:
• Health perception-health management pattern.
• Nutritional-metabolic pattern
• Elimination pattern
• Activity-exercise pattern
• Sleep-rest pattern
• Cognitive-perceptual pattern
• Self-perception-concept pattern
• Role-relationship pattern
• Sexuality-reproductive pattern
• Coping-stress tolerance pattern
• Value-belief pattern Carmela L. Domocmat, RN, MSN
Maria

44. Analyze data
Maria Carmela L. Domocmat, RN, MSN

45. Analyze data
• compare data against standard and
identify significant cues. Standard/norm
are generally accepted measurements,
model, pattern:
Maria Carmela L. Domocmat, RN, MSN

46. Analyze data
• Ex: Normal vital signs, standard Weight
and Height, normal laboratory/diagnostic
values, normal growth and development
pattern
Maria Carmela L. Domocmat, RN, MSN

47. Identifying patterns/testing first
impressions
Maria Carmela L. Domocmat, RN, MSN

48. Identifying patterns/testing first
impressions
• After clustering data into groups of
related information
• You get some initial impressions of
patterns of human functioning.
• But you must test these impressions
and decide if the patterns really are
as they appear
Maria Carmela L. Domocmat, RN, MSN

49. • Testing first impressions involves
– deciding what’s relevant
– making tentative decisions about what the
data may suggest,
– focusing assessment to gain more information
to fully understand the situations at hand
Maria Carmela L. Domocmat, RN, MSN

50. • like the puzzle analogy – you put some of
the puzzle pieces together and you think
you know what the picture looks like
Maria Carmela L. Domocmat, RN, MSN

51. Reporting and recording data or
Documentation of data
Maria Carmela L. Domocmat, RN, MSN

52. Reporting and recording data
• Reporting abnormal data in a timely
fashion expedites diagnosis and treatment
of urgent problems
• Recording data in a timely fashion
promotes continuity, accuracy, and critical
thinking
Maria Carmela L. Domocmat, RN, MSN

53. Documentation of data
• an important step of assessment because
it forms the database for the entire nursing
process and provides data for all other
members of the health care team
Maria Carmela L. Domocmat, RN, MSN

54. Documentation of data
• thorough and accurate documentation is
vital to ensure valid conclusions are made
when the data are analyzed in the second
step of the nursing process
Maria Carmela L. Domocmat, RN, MSN

55. Documentation of data
• nurse records all data collected about the
client’s health status
• data are recorded in a factual manner not
as interpreted by the nurse
• record subjective data in client’s word;
restating in other words what client says
might change its original meaning.
Maria Carmela L. Domocmat, RN, MSN

56. Documentation of data
• use anatomic landmarks in descriptions
• Ex: 1½ x 2 ½ wound located 2 ½ inches below the
umbilicus at the MCL
Maria Carmela L. Domocmat, RN, MSN

57. Documentation of data
• use anatomic landmarks in descriptions
• Ex: 1½ x 2 ½ wound located 2 ½ inches below the
umbilicus at the MCL
Maria Carmela L. Domocmat, RN, MSN

58. Documentation of data
• pinpoint findings by position on clock
»left breast, dominant 3-
cm mass at 1 o'clock
position, 2 cm from the
areolar border
Maria Carmela L. Domocmat, RN, MSN

59. Maria Carmela L. Domocmat, RN, MSN

60. End result of assessment
• formulation of nursing diagnoses (wellness,
risk, or actual) that require nursing care,
• the identification of collaborative problems
that require interdisciplinary care, and
» the identification of medical
problems that require
immediate referral
Maria Carmela L. Domocmat, RN, MSN