nursing assessment

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A SSESSMENT

ASSESSMENT-DEFINITION:

ASSESSMENT-DEFINITION Assessment is the deliberate and systematic collection of data to determine a client’s current and past health status and functional status and to determine the client’s present and past coping patterns. (Calpenito 2000)

CHARACTERISTICS OF AN ASSESSMENT:

CHARACTERISTICS OF AN ASSESSMENT PURPOSEFUL FOCUSED AND RELEVANT SYSTEMATIC COMPREHENSIVE AND ACCURATE RECORDED IN STANDARDISED WAY

TYPES OF NURSING ASSESSMENT:

TYPES OF NURSING ASSESSMENT INTTIAL ASSESSMENT FOCUSED ASSESSMENT EMERGENCY ASSESSMENT TIME LAPSED ASSESSMENT

PURPOSE OF ASSESSMENT :

PURPOSE OF ASSESSMENT To establish data base To determine the clients functional abilities and the presence or absence of dysfunction. 3. To assess clients normal routine for activities of daily living and life style patterns. 4. To identify clients strengths . 5. To offer an opportunity for the nurse to form a therapeutic interpersonal relationship with the client. 6. To provide and opportunity for the client to discuss health care concerns and goals with the nurse

SIX ACTIVITIES OF ASSESSMENT:

SIX ACTIVITIES OF ASSESSMENT Collecting Data :- gathering data (information ) about health status Validating (Verifying ) Data :- it is the act of confirming or verifying data. Organizing (clustering) Data :- Grouping related pieces of information to help you to identify patterns of health or illness ( eg :-clustering data about nutrition together, rest together etc. Documentation of Data :- documenting significant data

1. DATA COLLECTION :

1. DATA COLLECTION It is the process of gathering information about a clients health status PREPARING FOR DATA COLLECTION 1 Establishing Assessment Priorities 1 Health Orientation 2 Developmental stage 3 Need for Nursing 2 Structuring the Assessment

TYPES OF DATA :

TYPES OF DATA SUBJECTIVE DATA OBJECTIVE DATA CONSTANT DATA VARIABLE DATA

CHARACTERISTICS OF DATA :

CHARACTERISTICS OF DATA 1. Purposeful 2. Complete 3. Factual and accurate 4. Relevant

SOURCES OF DATA :

SOURCES OF DATA Client Support people Client records Health care professionals Literature Interdisciplinary conferences, rounds and consultations. Results of diagnostic tests

METHODES OF DATA COLLECTION:

METHODES OF DATA COLLECTION OBSERVATION INTERVIEW HEALTH HISTORY PHYSTCAL EXAMINATION LABORATORY AND DIAGNOSTIC DATA

METHODS OF DATA COLLECTION:

METHODS OF DATA COLLECTION 1. OBSERVATION Observation has two aspects 1 noticing the data 2 selecting, organizing and interpreting the data. 2. INTERVIEW APPROACHES : 1.Directive 2.Non-directive

INTERVIEW:

INTERVIEW STAGES OF INTERVIEW 1. PLANNING THE INTERVIEW AND SETTING 2. INTRODUCTION 3. WORKING PHASE 4. TERMINATION

INTERVIEW:

INTERVIEW PATIENT VARIABLES THAT CAN NEGATIVELY INFUENCE AN INTERVIEW 1. High Anxiety :- So the patient may speak rapidly or incoherently and may jump from one topic to another 2. Pain :- Patient offers clipped response and “yes” or “no” answers whenever possible 3. Language difficulty :- It occur if the patient not fluent in nurse’s language because patient speaks a different language, has a limited education. 4. Previous negative experiences with nurse or health care delivery system 5. Unrealistic expectations of health care professionals.

METHODS OF DATA COLLECTION:

METHODS OF DATA COLLECTION HEALTH HISTORY 1) Demographic Information 2) Reason for seeking Health care 3) Perception of Health status 4) Previous illnesses, Hospitalizations and surgeries 5) Client and Family Medical History 6) Immunizations and Exposure to Communicable Disease 7)Allergies

HEALTH HISTPRY:

HEALTH HISTPRY 8. Current Medications 9. Developmental Level 10. Psychosocial History 11. Socio cultural History 12. Activities of Daily Living

METHODS OF DATA COLLECTON:

METHODS OF DATA COLLECTON 4.PHYSICAL EXAMINATION Assessment Techniques 1) Inspection. 2) Palpation 3) Percussion 4) Auscultation 5. LABORATORY AND DIAGNOSTIC DATA

PROBLEMS OF DATA COLLECTION:

PROBLEMS OF DATA COLLECTION Inappropriate organization of the database Omission of pertinent data Inclusion of irrelevant or duplicate data Erroneous or misinterpreted data Failure to establish rapport and partnership Recording an interpretation of data rather than observed behavior Failure to update the database

ACTIVITIES OF ASSESSMENT:

ACTIVITIES OF ASSESSMENT 2. DATA VALIDATION Identifying data to be validated Identifying cues and making inferences 3. ORGANIZING (CLUSTSERING DATA) 4. DOCUMENTATION

. ORGANIZING (CLUSTSERING DATA):

. ORGANIZING (CLUSTSERING DATA) ASSESSMENT MODELS Holistic 1. Hierarchy of Human Needs 2. Functional Health Patterns 3. Human response patterns Medical Body system model

CONCLUSION:

CONCLUSION Assessment is the foundation of the nursing process. Accurate data collection leads to identification of the client’s health status, strengths and concerns for nursing diagnoses, which provides direction for nursing implementation and alleviation of that concerns.

REFERENCE:

REFERENCE Carol Taylor etal. FUNDAMENTALS OF NURSING. 6 th edition volume I Philadelphia, Wolters Klnwer. Lippincott Williams and Wilkins, 2008, page no: 241-260 Kozier etal, KOZIER AND ERB’S FUNDAMENTALS OF NURSING.. 8 th edition. New Delhi: Dorling Kindersley; 2008, page no 175-192 Sne C. Delaune, Patricia, k. Ladner, FUNDAMENTALS OF NORSING, 3 rd edition, Haryana; Sanat Printos; 2007, page no: 99-109 Potter and Perry.BASIC NURSING ESSENTIALS FOR PRACTICE.St. Louis, Mosby; 2003 page no: 73-78

REFERANCE:

REFERANCE . Delaune, Patricia, k. Ladner, FUNDAMENTALS OF NORSING, 3 rd edition, Haryana; Sanat Printos; 2007, page no: 99-109 Potter and Perry.BASIC NURSING ESSENTIALS FOR PRACTICE.St. Louis, Mosby; 2003 page no: 73-78 Rosalinda Alfara Leferne .APPLYING NURSING PROCESS. 6 th edition. Philadldephia; Lippincott Williams and Wilkins; 2006, page no 45-73 Marn Ellen Muray, Leshe D Atkinson UNDERSTANDING THE NURSING PROCESS. 6 th edition united states of America; Mc. Graw hill; 2008, page no 25-50 Paula J. Christensen, Janet w. Kenney, NURSING PROCo 61-69. JOURNAL 1. Nightingale nursing times: August 2006. volume 2, page 12 www.pubmed.com www.stagepub.com www.flipart.com

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THANK YOU