Basic Concepts of Communication Science in Nursing

NURSING ASSESSMENT

 
Definition of Nursing Assessment

Assessment is the basic thinking of the nursing process that aims to collect information or data about the client, in order to identify, recognize the problems, health and nursing needs of the client, both physical, mental, social and environmental. (Effendy, 1995).


The Purpose of Nursing Assessment

1. General: Collecting data relating to patients to establish nursing diagnoses, strengths (abilities) of patients and effective plans in patient care.
2. Specifically, can be used as;
   
   • Nursing assessment documentation
   • Main information (core) for patients and families
   • The basis for determining nursing diagnoses
   • Sources of information that can help diagnose new problems that arise
   • Support clinical decisions in order to achieve goals and actions accordingly
   • The basis determines the needs of patients, families and caregivers of patients
   • The basis for determining the patient's needs when returning
   • Basis for selection of care
   • Determination of maintenance costs
   • Protect legal rights
   • Patient care system components (able to determine the needs of care staff, patient care costs, etc.)

Types of Data

1. Primary Data
   Primary data sources are data collected from clients, which can provide comprehensive information about the health and nursing problems they face.
2. Secondary Data
   Secondary data sources are data collected from people closest to the client (family), such as parents, relatives, or other parties who understand and are close to the client.
3. Other Data
   Client records (client care or medical records) which is a history of the client's illnesses and treatments in the past.

Data Collection

Nurses collect data that is descriptive, concise and complete. The assessment does not include conclusions or interpretive statements that are not supported by the data. Descriptive data come from client perceptions about symptoms, family perceptions and observations, nurse observations, or reports from members of the health care team. For example, a client might describe his pain as "sharp, abdominal pain." Nurse observations can, "the client lies on his right side holding the abdomen, grimacing face". The nurse carries out a focused examination and notes observations only and avoids interpreting the behavior (eg "Clients tolerate pain poorly"). The concise data briefly describes the information obtained. Information is summarized in a short format using appropriate medical terms (e.g. "The client describes constant, sharp, vibrating pain in the right upper quadrant abdomen. Pain begins to be felt 48 hours before being treated in the hospital, 2 hours after eating foods that contain lots of fat. Pain does not eased with the use of antacids "). Complete data collection that results from gathering all information relevant to actual and potential health problems, apart from the client's reaction to the nurse. Nurses and clients are each affected by each other's behavior. The assessment must consider whether this interaction influences the client's behavior.
Inaccurate, incomplete, or inappropriate data collection leads to the identification of client care needs which are inaccurate and consequently nursing diagnoses that are made to be inaccurate, incomplete or incompatible. Inaccurate data occurs when nurses fail to gather information relevant to specific areas or if nurses are irregular or unskilled in assessment techniques. Data becomes incomplete if the nurse fails to collect all specific area information, draws conclusions about potential problems, or makes assumptions without validation. Data that is not appropriate is not related to the area being studied.


Data Sources

Data were obtained from clients, family, close friends, health care team members, health records, physical examinations, results from diagnostic and laboratory examinations, and related medical or personal literature. Each source provides information about the level of client welfare, the anticipated prognosis, risk factors, health practices and goals, and health and disease patterns, as well as information relevant to the client's health care needs.

1. Clients
   In most situations the client is the best source of information. Clients who are aware and answer questions properly can provide the most accurate information about health care needs, lifestyle patterns, current and past illnesses, perceptions about symptoms, and changes in daily life activities. However, it is also important to consider the environment in which nurses interact with clients.
2. Family and closest people
   Families and loved ones can be interviewed as primary sources of information about infants and children and clients who are critically ill.
3. Health care team members
   The health care team consists of doctors, nurses, other health professionals, and non-professional officers who work in a health care environment. Because assessment is an ongoing process, nurses must communicate with other members of the health care team. Each member of the health care team is a potential source of information, and the team can identify and communicate data and strengthen information from other sources.
4. Medical records
   Current and past clients' medical records can corroborate information about past health and treatment patterns or provide new information.
5. Other notes
   If the client receives services at a community health clinic or an outpatient clinic, the nurse must obtain data from this record but first obtain written permission from the client or client's guardian.
6. Literature review
   Reviewing the nursing, medical, and pharmacological literature about illness helps nurses complete basic data.
7. Nurse's experience
   The nurse's ability to carry out assessments will improve because of using past experience, applying relevant knowledge and focusing on data collection that avoids the useless consideration of unnecessary information.

Method of Collecting Data

1. Types of interview techniques
   Is a method of collecting data where the interviewer, the nurse, gets the client's response face to face.
   Interview Phase
   
   • Preparation
     The nurse prepares it by seeing the information about the client in the medical record. One time this may be limited if the nurse is the first person to deal with the client. The nurse also looks back at the literature relating to the client's health problems. The interview was conducted in a comfortable atmosphere, the situation as calm as possible.
   • Orientation
     The nurse lays out the purpose of the interview and knows the client closely. The client learns about the types of questions to be asked. Clarification is given with respect to confidentiality of information. The professional approach of the nurse inspires client confidence. This is very important if the nurse wants to learn about the client's motivation, strengths and resources. The nurse helps the client cope with anxiety, helplessness and personal background and information to be discussed.
   • Work phase
     Nurses focus interviews on the client's health dimension, using a model that forms a baseline to identify nursing diagnoses that may occur. Nurses use interviewing skills to clarify and validate information so that appropriate clinical problem solving can be carried out. The collected data will be strengthened by the findings from physical examination. The nurse and client work together in identifying problems and choosing care goals.
   • Termination phase
     The nurse ends the interview by concluding the collected data. Problems or diagnoses and goals that are validated with the client. The nurse explains how additional contact will be carried out with the client, including preparation for physical examination. This helps give clients instructions when the interview ends.
   In an emergency situation requires a type of interview technique where the nurse asks focus questions relating to the client's physical status. Nurses can use a variety of interviewing techniques to get the information needed from clients or other sources.
   
   • Techniques for Finding Problems. Interviews look for problems identifying potential problems of the client, and subsequent data collection focuses on the problem.
   • Problem Solving Techniques. Problem-solving interview techniques focus on collecting deeper data on specific problems identified by the client or nurse.
   • Direct Question Technique. Direct question interviews are structured formats that require one or two-word answers and are often used to clarify previous information or provide additional information.
   • Open Question Technique. Open-ended interview questions are intended to get a response of more than one or two words. This technique leads to a discussion where the client actively outlines their health status.
2. Nursing Health History
   Nursing medical history is data collected about the level of client's well-being (current and past), family history, changes in life patterns, social history, spiritual health, and mental and emotional reactions to illness. The nursing history was collected during the interview and was the first step in conducting the assessment.
   
   • Biographical Information
     Biographical information is factual demographic data about the client. The client's age, address, occupation and employment status, marital status and type of insurance covered must be included.
   • Client's expectations
     Assessing client expectations is not the same as reasons for seeking health care, although sometimes it is often related. It becomes more important for nurses to know what is important for clients who are looking for health care.
   • Current Disease
     If there is an illness, the nurse collects important and related data about the onset of symptoms. The nurse determines when symptoms begin suddenly or gradually, and whether the symptoms always appear or disappear and appear. In the section on current medical history, nurses record specific information such as the location, intensity and quality of symptoms.
     It is also useful to study client expectations about health care providers. Such expectations provide nurses with information about the client's perception of disease patterns or changes in lifestyle.
   • Past Medical History
     Information collected about past history provides data about the client's health care experience. The nurse examines whether the client has been hospitalized or has had surgery. Also important in planning nursing care is a description of allergies, including allergic reactions to food, drugs.
     Nurses also identify lifestyle habits and patterns. The use of tobacco, alcohol, caffeine, drugs, or medications that are routinely used can make clients at risk for liver disease and others.
   • Family History
     The purpose of family history is to obtain data on direct family relationships and blood relations. The goal is to determine whether the client is at risk of genetic or familial diseases and to identify areas of health promotion and disease prevention. Family history also provides information about family structure, interactions, and functions that may interfere in planning care.
   • Psychosocial History
     A complete psychosocial history shows who the client support system includes spouses, children, other family members, or close friends. Psychosocial history includes information about ways that clients and family members usually use to deal with stress.
   • Spiritual Health
     Life experiences and life events shape a person's spirituality. The spiritual dimension represents the totality of one's life and is difficult to examine quickly. Nurses ask clients for their beliefs about their lives, their source for guides in living their beliefs.
   • System Overview
     System review is a systematic method for gathering data on all body systems. The system studied depends on the client's condition and urgency in providing nursing. During the system review the nurse asks the client about the normal functioning of each system and any known changes. These changes are subjective data because they are described as what the client says.
3. Physical Assessment
   Physical assessment and collection of laboratory and diagnostic data includes the collection of objective, observable information that is not obscured by the client's perception. Physical examination is measuring vital signs and other measurements as well as examining all parts of the body using inspection, palpation, percussion, auscultation techniques.
   During physical inspection, the data is measured against the standard, which is a regulation that has been set or basis for comparison in the measurement or assessment of the capacity, quantity, content and value of objects in the same category.
   Before conducting a physical examination, the nurse prepares the client, the environment, and the equipment needed. The nurse informs the client about the physical examination process, specifically about the goals, the nurse's role, the client's role, and the estimated time needed.
   
   • Inspection Order
     The physical examination is carried out in a systematic manner as is the case with a review of the system in medical history. This assessment component usually starts with data about the client's weight and height and vital signs. Next the examiner writes a general statement about the client's perception and health level of the client. The latest information is a body examination from the top of the head to the toe. The examination records objective data obtained, using clear, concise, and appropriate language in describing each system that is examined.
   • Physical Examination Techniques
     Nurses use inspection, palpation, percussion, and ausculortation to examine the client thoroughly. Each technique requires certain principles that must be followed to ensure accurate data collection.
     Types of physical examination:
     
     • Inspection
       Is an examination carried out by looking at the body parts examined through observation. The results are like: Yellow eye (icteric), there is a goitre in the neck, bluish skin (cyanosis), etc.
     • Palpation
       A physical examination is carried out through touching the parts of the body that have abnormalities. For example the presence of tumors, edema, crepitus (broken / fractured bones),
     • Auscultation
       Is a physical examination done through hearing. Usually using a tool called a stethoscope. The things that are listened to are: heart sounds, breath sounds, and bowel sounds.
     • Percussion
       Physical examination is done by tapping the body using a hand or aids such as reflex hammer to find out someone's reflexes (specifically discussed). Also carried out other checks relating to the physical health of the client. For example: bloating, heart borders, lung limit (knowing lung development).
4. Diagnostic and Laboratory Data
   The final assessment data source is the result of diagnostic and laboratory examinations. This examination is very important, meaning for nurses to examine the results of this examination to ensure the changes identified in the medical history of nursing and physical examination. Laboratory data can help identify actual or potential health care problems that were not previously known to the client or examiner.
   Laboratory tests are chosen based on symptoms or illness, a common examination may be used for most clients. Specific laboratory tests and nursing responsibilities with this intervention in detail.
5. Validation
   Data validation is a comparison of subjective data with objective data collected from primary (client) and secondary sources (for example health records) with accepted values ​​and norms. A standard value is a rule or measure that is commonly used.
   The nurse compares client comments, subjective data with measurable client objective data. The nurse checks whether objective data validates subjective data. The nurse checks whether the client's, subjective, objective values ​​lie within the normal range of values ​​and standards commonly used, such as normal vital signs, laboratory values, diagnostic tests, basic food groups, normal growth and development.

Formulate Nursing Assessment

To be useful, assessment data must refer to goals intended in nursing that indicate a client's health problem (Bandman & Bandman, 1995). This concept of copy relating is the basis for nursing judgment. The nurse critically chooses the type of information collected about the client, interprets the information to determine the abnormality, makes further observations to clarify the information, and then mentions the client's problem in the format of the nursing diagnosis.

1. Data Interpretation
   Care collects a lot of information about the client. Through the process of considering conclusions and judgments, the nurse decides what information has meaning in relation to the client's health status. Balanced conclusions include the process of matching new meanings with known clinical data.
   Problem assessment means gathering, estimating, and assessing the significance and value of data. This means that nurses always think, analyze data about clients to make accurate and meaningful interpretations of client problems.
2. Data Grouping
   After collecting and validating subjective and objective data and interpreting the data, the nurse organizes the information into meaningful groups. This depends on the introduction of significant signals. There are times when assessment data show clearly on certain nursing diagnoses.
   During the grouping of data, the nurse organizes the data and focuses on client functions that need support and help for recovery. The next step is to form nursing diagnoses from data that has been grouped to develop specific nursing interventions for client nursing.

Data Documentation

Data documentation is the last part of a complete assessment. Completeness and accuracy are required when recording data. If something is not recorded, it is lost and is not available in the database. Completeness in the documentation is important for two reasons. First, all data relating to the client's status is entered. Even information that seems to indicate skeletal abnormalities must be recorded. This information may be related later, and serve as a base value for changes in status. The general rule that applies is, if it is reviewed it must be noted.
Second, observation and recording of client status is a legal and professional responsibility. Nurse practice laws in all states, and require data collection and record keeping as an independent function essential for the role of professional nurses. Being factual is easy after it becomes a habit.


REFERENCES

• Berger, J. Karen and Williams. 1999. Fundamental Of Nursing; Collaborating for Optimal Health, Second Editions. Apleton and Lange. Prenticehall.USA
• Poter & Perry. 2005. Nursing Fundamentals Handbook: concepts, processes, and practices
• www.nursingworld. 1998: Collaborations and Independent Practice: Ongoing Issues for Nursing.

Tag : Nursing Education