BarCharts - Nursing: Assessment

• Nursing assessment is the first stage of the nursing process
• It includes the gathering of information about a clients physiological,psychological, sociological and spiritual status
• The purpose of assessment is to identify the clients nursing problems and nursing care needs

• Symptom: A subjective experience by the client
• Sign: An objective finding by the examiner/practitioner

• Obtain baseline data and expand the database from which subsequent phasesof the nursing process can evolve
• Identify and manage a variety of client problems
• Evaluate the effectiveness of nursing care
• Provide data for planning interventions
• Enhance the nurse/client relationship
• Make clinical judgments

• Note the clients name, age, address, race, occupation and religion
• The chart provides a starting point for coming to know the client as a person
• Information on the chart gives you an idea of the clients lifestyle
• Chart data may identify risk factors

• Greet the client in a friendly, non-threatening manner
• Explain your role in client careyour first impression can earn the clients trustand confidence
• Share with the client the purpose of the assessment: the assessment willprovide a baseline picture of your health status

• Give privacy by drawing the curtain, closing the door
• Excuse family members so the client can talk candidly with you

• Clothe client in a loose-fitting gown, providing easy access for inspection andpalpation of body
• Respect personal space: Stay three feet away from the client to avoid invadingpersonal space; for some portions of the examination closer proximity isneeded, but personal space needs to be respected
• Ask permission when touching the person, especially private or sensitive areasof the body

• Looking
  • overall appearance, signs of distress or discomfort
  • color of skin, nails and hair
  • skeletal deformities or use of assistive aids
• Listening
  • interactions with provider and others
  • congruence of verbal and non-verbal actions
• Smelling
  • the presence of any peculiar odors from the body
  • the presence of odors from substances ingested or applied to the body

• Identifies strengths, actual or potential health problems, support systems,teaching needs and referral needs from the clients perspective

Collecting a nursing historyrequires careful listening anduse of therapeutic questions tohear the clients concerns

A structured interview prior to the physicalexamination is known as a nursing history.

Analysis of a Symptom

P rovokes: What makessymptoms better or worse?

Q uality: What does it feel like?

R adiation: Where is thesymptom and where does it go?

S everity: How bad does it feelon a scale of 1 to 10?

T ime: When does it occur,how often, and how long doesit last?

Four assessment techniques are used in a physical examination: inspection,palpation, percussion and auscultation.

This is the close, careful and unhurried visualization of the client as a whole andalso of each body system.

This is the purposeful and careful feeling with the hands during a physicalexamination. The health-care provider touches and feels the clients bodyto examine the size, consistency, texture, location and tenderness of anorgan or body part.