Lesson 1, Topic 1
In Progress

Assessment Data

May 1, 2021

According to the American Nurses Association (ANA), the current definition of nursing states, “Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (ANA, 2013). This broad definition seeks to illustrate nursing’s growth as a profession. The nursing process serves as the organizational framework for the practice of nursing.

The nursing process is a systematic method by which nurses plan and provide care for patients. This involves a problem-solving approach that enables the nurse to identify patient problems and potential problems. Once these problems are identified, the nurse is then able to plan, deliver, and evaluate nursing care in an orderly, scientific manner. The nursing process consists of the following six dynamic and interrelated phases: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation (Figure 5-1). Box 5-1 describes how the nursing process is carried out by the registered nurse (RN) and licensed practical/vocational nurse (LPN/LVN). (The licensed practical/vocational nurse [LPN/LVN] has a significant role in the nursing process, which is discussed subsequently in the chapter.)

Assessment Data

The ANA defines assessment as “a systematic, dy­namic process by which the registered nurse, through interaction with the patient, family, groups, communities, populations, and health care providers, collects and analyzes data. Assessment may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, functional abilities, developmental, economic, and lifestyle” (ANA, 2010). Information is gathered by the nurse to identify the condition of the patient’s health. The nurse performs a patient assessment on initial contact with the patient, with the remaining phases of the nursing process dependent on the accuracy and completeness of this initial data collection. Either a complete assessment or a focused assessment is performed, depending on the patient’s status and the type of facility. The LPN/LVN assists the registered nurse by performing ongoing complete and focused assessments of patients, depending on the facility and scope of practice within a state.
A complete assessment involves a review and physical examination of all body systems (musculoskeletal, respiratory, gastrointestinal, etc.) (see Chapter 12). This type of assessment also includes cognitive, psychosocial, emotional, cultural, and spiritual components and is appropriate for a patient with a stable condition who is not in acute distress. Information about functional abilities, lifestyle, and developmental concerns is also important.

A focused assessment is advisable when the patient is critically ill, disoriented, or unable to respond. A focused assessment is used to gather information about a specific health problem. For example, if the patient reports abdominal distention, lack of appetite, and straining to have a bowel movement, one possible nursing diagnosis to suspect is constipation. For further investigation, the nurse may ask additional questions about intake of foods high in fiber, fluid intake, and amount of exercise.

Focused assessments are also performed continuously throughout nurse-patient contact. The nurse who monitors intake and output, skin turgor, and oral mucous membranes is performing a focused assessment for deficient fluid volume (Ackley and Ladwig, 2011). Assessments made to determine progress toward the achievement of desired outcomes are also focused assessments.

Types of Data

In an assessment, the nurse gathers subjective and objective data. A cue is a piece or pieces of data that often indicates that an actual or potential problem has occurred or will occur. Subjective data refer to information that is provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Other terms for subjective data are symptoms and subjective cues. Subjective data are hidden until shared by the patient.
Objective data are observable and measurable signs. For example, the LPN/LVN is able to observe capillary refill, measure a patient’s blood pressure, and observe and measure edema. Other terms for objective data are signs and objective cues. Table 5-1 shows a comparison of subjective and objective data.

Sources of Data

Data are obtained from primary or secondary sources. The primary source of data is the patient. In most instances, the patient is considered to be the most accurate reporter. The alert and oriented patient is able to provide information about past illnesses and surgeries and present signs, symptoms, and lifestyle.
When the patient is unable to supply adequate information because of deterioration of mental status, age, or seriousness of illness, the nurse turns to secondary sources. Secondary sources include family members, significant others, medical records, diagnostic procedures, and previous nursing progress notes. Members of the patient’s support system are often able to furnish information about the patient’s past health status, current illness, allergies, and current medications.

Health team professionals are also helpful secondary sources. Health care providers, nurses, dietitians, respiratory and physical therapists, and others frequently provide data about the patient. The nurse should review nursing literature to determine what information may be needed. Nursing textbooks are a good resource for information about etiology (cause), pathophysiology, clinical manifestations, assessment, diagnostic tests, medical management, nursing interventions, patient teaching needs, and prognosis. This important information then guides further data collection.

Methods of Data Collection

Two basic methods are used to collect data. In the first method, the nurse conducts an interview, the nursing health history, to obtain information about the patient’s health history. The nurse commonly assesses several common components in the course of the interview. Biographic data provide information about the facts or events in a person’s life. Additional information collected includes the reason the patient is seeking health care, a history of the present illness, the health history, and the family history. Because the environment in which the patient lives and works often plays a part in the patient’s health status, an environmental history is important to obtain. A psychosocial history yields information about a combination of psychological and social factors. When gathering information about the function of each body system, the nurse follows the nursing health history with a review of systems.

The second method of data collection is the physical examination. The physical examination is often guided by subjective data provided by the patient. For example, the nurse should follow up with a thorough assessment of any body part or system for which the patient has reported symptoms or concerns. A head-to-toe format provides a systematic approach that helps avoid omission of important data (see Chapter 12).

A completed nursing health history and a physical examination allow the nurse to establish a database (a large store or bank of information) for the patient. Analysis of the database leads to the identification of nursing diagnoses. In addition, the database makes information available for the health care provider who assists in the medical management of the patient and all health care personnel who are involved in the patient’s care.

Data Clustering

Data obtained from the health history, physical examination, and related diagnostic procedures are analyzed in development of a plan of care. Data clustering is one method of data organization. The clustering of related data helps to identify patterns that assist with the identification of nursing diagnoses. Some schools of nursing or health care facilities use the term defining charac­teristics as a synonym for data clustering. Examples of data clustering and the related nursing diagnosis include:

•Urine loss associated with physical exertion and urine loss associated with increased abdominal pressure are cues for the nursing diagnosis of stress urinary incontinence (Ackley and Ladwig, 2011).
•Abnormal blood pressure and heart rate response to activity, exertional dyspnea, verbal report of fatigue or weakness are cues for the nursing diagnosis of activity intolerance (Ackley and Ladwig, 2011).