FUNDAMENTALS OF NURSING

Module 2: Nursing Assessment

Ins�tute of Health and Sciences and Nursing

 Module 2: Nursing Assessment

Objectives:
1. Identify the purpose of assessing
2. Identify the four major activities associated with the assessing phase.
3. Differentiate objective and subjective data and primary and secondary data.
4. Identify three methods of data collection and give examples of how each is useful
5. Compare directive and nondirective approaches to interviewing
6. Compare closed and open-ended questions, providing examples and listing
advantages and disadvantages of each
7. Describe important aspects of the interview setting
8. Contrast various frameworks used for nursing assessment

Key Concepts
1. The five phases of the nursing process are:
• Assessment - collecting, organizing, validating, and documenting data in order
to establish a database about the client’s response to health concerns or illness
and the ability to manage healthcare

• Diagnosis - includes analyzing and synthesizing data in order to identify client

strengths as well as health problems that can be prevented or resolved by
collaborative and independent nursing interventions and to develop a list of
nursing and collaborative problems

• Planning - includes determining how to:

o prevent, reduce, or resolve the identified priority client problems
o support client strengths
o implement nursing interventions in an organized, individualized, and
goal-directed manner in order to develop an individualized care plan that
specifies client goals/desired outcomes and related nursing
interventions

• Implementation - includes:
o carrying out (or delegating) and documenting the planned nursing
interventions in order to assist the client to meet desired goals/outcomes
o promote wellness
o prevent illness and disease
o restore health
o facilitate coping with altered functioning

Ins�tute of Health and Sciences and Nursing

 Module 2: Nursing Assessment

• Evaluation - includes:
o measuring the degree to which goals/outcomes have been achieved
and identifying factors that positively or negatively influence goal
achievement in order to determine whether to continue, modify, or
terminate the plan of care

2. The nursing process has distinctive characteristics that enable the nurse to respond
to the changing health status of the client. These characteristics include its:
• cyclic and dynamic nature
• client centeredness
• a focus on problem solving and decision making
• interpersonal and collaborative style
• universal applicability, use of critical thinking, and use of clinical reasoning

3. The purpose of assessing is to establish a database about the client’s response to

health concerns or illness and the ability to manage healthcare needs and is a
continuous process carried out during all phases of the nursing process.

4. There are four types of assessment:

• initial assessment
• problem-focused assessment
• emergency assessment
• time-lapsed reassessment.

Ins�tute of Health and Sciences and Nursing

 Module 2: Nursing Assessment

5. There are two types of data:

a. Subjective data, also referred to as symptoms or covert data, are apparent only to
the person affected and can be described only by that person. Subjective data include
the client’s sensations, feelings, values, beliefs, attitudes, and perception of personal
health status and life situations.

b. Objective data, also referred to as signs or overt data, are detectable by an observer
or can be measured or tested against an accepted standard. Objective data can be
seen, heard, felt, or smelled and are obtained through observation or physical
examination.

6. The primary source of data is the client

7. All sources of data other than the client are considered secondary sources or indirect
sources. These include family and other support people, other healthcare
professionals, records and reports, laboratory and diagnostic analyses, and relevant
literature. All data from secondary sources should be validated, if possible

8. The principal methods used to collect data are:

• Observing
• Interviewing
• Examining

 To observe means to gather data by using the senses. Although nurses

observe mainly through sight, most of the senses are engaged during careful
observation. Observation is useful for gathering data such as skin color or
lesions (vision), body or breath odors (smell), lung or heart sounds (hearing),
and skin temperature (touch).

 Interviewing is a planned communication or a conversation with a purpose.

Interviewing is useful to identify problems of mutual concern, evaluate change,
teach, provide support, or provide counseling or therapy.

 Examining, referred to as physical examination or physical assessment, is a

systematic data collection method that uses observation (i.e., the senses of
sight, hearing, smell, and touch) and techniques of inspection, auscultation,
palpation, and percussion to detect health problems. Examining is useful for
assessing all body parts and comparing findings on each side of the body.

Ins�tute of Health and Sciences and Nursing

 Module 2: Nursing Assessment

9. The interviewing approach can be directive or nondirective.

 A directive interview is highly structured and elicits specific information. The nurse
establishes the purpose of the interview and controls the interview. Nurses
frequently use directive interviews to gather and to give information when time is
limited (e.g., in an emergency situation)

 During a nondirective interview, or rapport-building interview, the nurse allows the

client to control the purpose, subject matter, and pacing. A combination of directive
and nondirective approaches is usually appropriate during the information-
gathering interview

10. Questioning techniques for interviewing include both closed and open-ended
questions

 Closed questions are restrictive and generally require only “yes” or “no” or short
factual answers giving specific information. Closed questions often begin with
“when,” “where,” “who,” “what,” “do,” or “is.”

Examples of closed questions are “What medications did you take?” or “Are you
having pain now?”

 Open-ended questions invite clients to discover and explore, elaborate, clarify,

or illustrate their thoughts or feelings. An open-ended question specifies only
the broad topic to be discussed, invites answers longer than one or two words,
and gives clients the freedom to divulge only the information that they are ready
to disclose. The open-ended question is useful at the beginning of an interview
or to change topics and to elicit attitudes. Open-ended questions may begin
with “what” or “how.” Examples of open-ended questions include “How have
you been feeling lately?” or “What would you like to talk about today?”

11. Each interview is influenced by time, place, seating arrangement, distance, and
language.

 Nurses need to plan interviews for when clients are physically comfortable and
interruptions are minimal. Schedule interviews in the home at a time selected
by the client

 A well-lit, well-ventilated room that is relatively free of noise, movements, and

distractions encourages communication. A place where others cannot overhear
or see the client is necessary.

 In the hospital, if the nurse stands and looks down on the client, the nurse risks
intimidating the client. Sitting at a 45-degree angle to the bed is less formal than
sitting behind a table or standing at the foot of the bed. The client may feel less
confronted if there is an over-the-bed table between the client and nurse during

Ins�tute of Health and Sciences and Nursing

 Module 2: Nursing Assessment

the initial interview. A seating arrangement with the nurse behind a desk and
the client seated across suggests a formal, superior, and subordinate setting.
If both parties sit on chairs at right angles to a desk or table a few feet apart, a
less formal atmosphere is created and the nurse and client feel on equal terms.
In groups, a horseshoe or circular chair arrangement can avoid a superior or
head-of-the-table position.

 The distance between the interviewer and interviewee should be neither too
small nor too great because people feel uncomfortable when talking to
someone who is too close or too far away

 Failure to communicate in a language the client can understand is a form of

discrimination. The nurse must convert medical terminology into common
English usage. Interpreters or translators are needed if the client and the nurse
do not speak the same language or dialect.

12. Data is then validated by double-checking the information, differentiating between

cues and inferences, and being aware of personal biases.

13. To complete the assessment phase, the nurse records client data. Accurate
documentation is essential and should include all data collected about the client’s
health status. Data are recorded in a factual manner and not interpreted.

Study Questions
1. What are the four different types of assessment?
2. What are the four activities involved in the assessment process?
3. When does the observation portion of data collection occur?
a. On the initial assessment
b. Prior to the initial assessment
c. It is an ongoing process.
d. Observation is not part of data collection

Reference:
1.Kozier and Erbs. Fundamentals of Nursing: Concepts Process and Practice. 11th
Edition. Pearson Prentice Hall, 2010

Ins�tute of Health and Sciences and Nursing