Fundamentals of Nursing and Midwifery 2e

Chapter 15 Assessing

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TABLE 15-1 Examples of assessment frameworks

Human needs (Maslow)

Functional health patterns (Gordon)

Head-to-toe

Physiological (survival) needs: Food, fluids, oxygen, elimination, warmth, physical comfort Safety and security needs: Things necessary for physical safety (e.g. a walking cane) and psychological security (e.g. a child’s favourite toy) Love and belonging needs: Family and significant others Self-esteem needs: Things that make people feel good about themselves and confident in their abilities (e.g. being well groomed, having accomplishments recognised) Self-actualisation needs: Need to grow, change and accomplish goals

Health perception/health management: Perception of well-being and adherence to preventive health practices

Head and face: Symmetry, cranial nerves, hair Eyes: Visual acuity, colour vision, extraocular muscles, internal and external structures Ears and nose: Otoscopic exam, nostril patency, olfactory sense Mouth and throat: Breath odour, mucous membranes, gag reflex Neck: range of motion (ROM), musculature, carotid arteries, jugular veins, lymph nodes Upper extremities: Nail beds, joints, ROM, pulses Back, posterior and lateral thoraxes: Spine, thoracic expansion, diaphragmatic excursion Heart: Pulsations, thrills, apical pulse, cardiac landmarks Breasts: Colour, vascularity, thickening, oedema, size, lymph nodes, gynaecomastia Abdomen: Contour, symmetry, pigmentation, colour, scars, striae, visible peristalsis, masses, pulsations, bowel sounds Inguinal area: Lymph nodes, inguinal hernias, femoral pulses Lower extremities: Colour, capillary refill, ulcerations, hair distribution, varicose veins, oedema, popliteal/dorsalis pedis/posterior tibial pulses, ROM, muscle size, tone, temperature Genitalia, anus and rectum: External and internal genitalia

Nutritional–metabolic: Patterns of food and fluid intake, electrolyte balance, general ability to heal Elimination: Patterns of excretory function (bowel, bladder, skin) and person’s perception Activity/exercise: Pattern of exercise, recreation and factors that interfere with desired or expected individual patterns Cognitive–perceptual: Adequacy of vision, hearing, taste, touch, smell, pain perception, cognitive functional abilities Sleep/rest: Quality, quantity and patterns of sleep and rest-relaxation during 24-hour day Self-perception/self-concept: Attitudes about self, perception of abilities, body image and identity Role/relationship: Perception of major roles and responsibility in current life situation Sexuality and reproductive: Perceived satisfaction or dissatisfaction with sexuality and reproductive state Coping/stress tolerance: General coping pattern, stress tolerance and ability to control or manage situations Values/beliefs: Values, goals or beliefs that guide choices or decisions

Characteristics of data Data are not only subjective or objective, they also have additional characteristics. When collecting and recording personal data, nurses and midwives ensure that the data are complete, factual and accurate, and relevant. Complete It is important that as much health data as possible are identi- fied in order to understand the problem(s) and develop a plan

admits that her parents are worried and that she has been skipping meals as she is so busy with work, tennis and study. Clarify in your mind the difference and the relationship between subjective and objective data by answering the following questions: 1. Can you differentiate between the objective and sub- jective data that you have gathered as part of your health assessment of Claire? 2. Why are the subjective data so important in the assessment phase?