Evaluating
care
Identifying
health problems
Planning care
Implementing
care
Assessing
• Identify assessment
priorities determined by the
purpose of the assessment
and the person’s condition
• Organise or cluster the data to
ensure systematic collection
• Establish the data base
• Continuously update the
database
• Validate data
• Communicate data
Review of the patient record and nursing literature
Consultation with the person’s support people
and healthcare providers
Health history
Physical examination
Unit III Thoughtful practice and the process of care
272
BOX 15-2 Assessment
Collect and verify information to determine the person’s:
•
Understanding of the reason for admission and care
processes
•
Expectations of services
•
Personal preferences such as requirements for
privacy, comfort measures, eye contact when
communicating and decision-making processes
•
Gender-appropriate care provision requirements
•
Cultural and linguistic background
•
Family or significant other relationships and lifestyle
patterns
•
Health beliefs, rules and usual health behaviours,
including diet, food preparation and presentation,
exercise patterns and personal care
•
Need for interpreter services to identify topics of
discussion or practices that are taboo for the
individual and family, such as personal hygiene,
illness or treatment
•
Need for culturally appropriate greetings and
farewells for nursing and midwifery staff, behaviours
that denote respect and preferred use of their name
•
Ability to read own language.
During this assessment many aspects and dimensions of the
person’s life should be explored and examined (including
such things as their values, cultural, social or familial beliefs
about health and illness); see Box 15-2. The person and their
family or significant others should be encouraged to be
actively involved throughout this assessment process.
Source: Chenoweth et al., 2006.
Many experienced nurses and midwives use intuition as a
component of the assessment process. Students are encour-
aged to use a systematic approach when performing
assessments and formulating their conclusions based on
those findings. Intuitive thinking comes with experience and
practice; however, it should not replace the systematic
assessment process where quantifiable data are collected.
See Chapter 14 for an outline of intuitive thinking as part of
the clinical reasoning process.
TYPES OF HEALTH ASSESSMENTS
Health assessments include the comprehensive initial
assessment, the focused assessment, the emergency assess-
ment and the time-lapsed assessment. This chapter will
focus on assessing the health status of a person. As you
develop expertise in health assessments, you will be able to
assess communities and special populations, such as school
children, older people or people with infectious diseases.
Your learning, through reflection, can now be applied to
enrich your understanding of the following types of assess-
ment performed by nurses and midwives.
Initial assessment
The
initial assessment
is performed shortly after the person
is admitted to a healthcare facility or service. Most institu-
tions have policies specifying the time interval within which
the assessment must be completed. The purpose of this initial
assessment is to establish a comprehensive database for iden-
tifying health problems and strengths, and for planning care.
Data are collected concerning all aspects of the person’s
health, establishing priorities for ongoing focused assess-
ments and creating a reference for future comparison.
Figure 15-1
Assessing. The primary source of personal
information is the person. Resources include
the person’s support people, the personal
record, information from other healthcare
providers and information from nursing and
midwifery and healthcare literature