What type of assessment that is performed during any physiologic or psychologic crisis of the client?

• it is systematic and continuous collection, validation and communication of client data as compared to what is standard/norm.
• it includes the client’s perceived needs, health problems, related experiences, health practices, values and lifestyles.

Purpose: To establish a data base (all the information about the client):

• nursing health history
• physical assessment
• the physician’s history & physical examination
• results of laboratory & diagnostic tests
• material from other health personnel

4 Types of Assessment:

a. Initial assessment – assessment performed within a specified time on admission

Ex: nursing admission assessment

b. Problem-focused assessment – use to determine status of a specific problem identified in an earlier assessment

Ex: problem on urination-assess on fluid intake & urine output hourly

c. Emergency assessment – rapid assessment done during any physiologic/physiologic crisis of the client to identify life threatening problems.

Ex: assessment of a client’s airway, breathing status & circulation after a cardiac arrest.

d. time-lapsed assessment – reassessment of client’s functional health pattern done several months after initial assessment to compare the clients current status to baseline data previously obtained.

Activities:

1. Collection of data
2. Validation of data
3. Organization of data
4. Analyzing of data
5. Recording/documentation of data

Assessment = Observation of the patient + Interview of patient, family & SO + examination of the patient + Review of medical record

I. Collection of data

• gathering of information about the client
• includes physical, psychological, emotion, socio-cultural, spiritual factors that may affect client’s health status
• includes past health history of client (allergies, past surgeries, chronic diseases, use of folk healing methods)
• includes current/present problems of client (pain, nausea, sleep pattern, religious practices, meds or treatment the client is taking now)

Types of Data:

• also referred to as Symptom/Covert data
• information from the client’s point of view or are described by the person experiencing it.
• information supplied by family members, significant others, other health professionals are considered subjective data.

Example: pain, dizziness, ringing of ears/Tinnitus

• also referred to as Sign/Overt data
• those that can be detected, observed or measured/tested using accepted standard or norm.

Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin

Methods of Data Collection:

• a planned, purposeful conversation/communication with the client to get information, identify problems, evaluate change, to teach, or to provide support or counseling.
• it is used while taking the nursing history of a client

1. Observation – use to gather data by using the 5 senses and instruments.

• systematic data collection to detect health problems using unit of measurements, physical examination techniques (IPPA), interpretation of laboratory results.
• should be conducted systematically:

1. Cephalocaudal approach – head-to-toe assessment
2. Body System approach – examine all the body system
3. Review of System approach – examine only particular area affected

Source of data:

1. Primary source – data directly gathered from the client using interview and physical examination.
2. Secondary source – data gathered from client’s family members, significant others, client’s medical records/chart, other members of health team, and related care literature/journals.

In the Assessment Phase, obtain a Nursing Health History – a structured interview designed to collect specific data and to obtain a detailed health record of a client.

Components of a Nursing Health History:

• Biographic data – name, address, age, sex, martial status, occupation, religion.
• Reason for visit/Chief complaint – primary reason why client seek consultation or hospitalization.
• History of present Illness – includes: usual health status, chronological story, family history, disability assessment.
• Past Health History – includes all previous immunizations, experiences with illness.
• Family History – reveals risk factors for certain disease diseases (Diabetes, hypertension, cancer, mental illness).
• Review of systems – review of all health problems by body systems
• Lifestyle – include personal habits, diets, sleep or rest patterns, activities of daily living, recreation or hobbies.
• Social data – include family relationships, ethnic and educational background, economic status, home and neighborhood conditions.
• Psychological data – information about the client’s emotional state.
• Pattern of health care – includes all health care resources: hospitals, clinics, health centers, family doctors.

II. Validation of Data – the act of “double-checking” or verifying data to confirm that it is accurate and complete.

Purposes of data validation:

1. ensure that data collection is complete
2. ensure that objective and subjective data agree
3. obtain additional data that may have been overlooked
4. avoid jumping to conclusion
5. differentiate cues and inferences

Cues – subjective or objective data observed by the nurse; it is what the client says, or what the nurse can see, hear, feel, smell or measure.

Inferences – the nurse interpretation or conclusion based on the cues.

Example: red, swollen wound = infected wound
Dry skin = dehydrated

III. Organization of Data – uses a written or computerized format that organizes assessment data systematically.

– Maslow’s basic needs

– Body System Model

– Gordon’s Functional Health Patterns:

1. Health perception-health management pattern.
2. Nutritional-metabolic pattern
3. Elimination pattern
4. Activity-exercise pattern
5. Sleep-rest pattern
6. Cognitive-perceptual pattern
7. Self-perception-concept pattern
8. Role-relationship pattern
9. Sexuality-reproductive pattern
10. Coping-stress tolerance pattern
11. Value-belief pattern

IV. Analyze data – compare data against standard and identify significant cues. Standard/norm are generally accepted measurements, model, pattern:

Ex: Normal vital signs, standard Weight and Height, normal laboratory/diagnostic values, normal growth and development pattern

V. Communicate/Record/Document Data

• nurse records all data collected about the client’s health status
• data are recorded in a factual manner not as interpreted by the nurse
• record subjective data in client’s word; restating in other words what client says might change its original meaning.

What Do You Think?

The nurse initiates the interview by stating his or her name and status, identifying the purpose of the interview, and clarifying the roles of nurse and patient. A typical introduction might run like this: “Good afternoon, Miss LeBon. My name is Nick Maraldo and I’ll be your student nurse. Right now I’d like to ask you a few questions about yourself so that we can plan your nursing care together. Feel free to respond only to those questions you feel comfortable answering, and know that your responses will be treated confidentially by the staff.This will take about 20 minutes. Is this time convenient for you? Do you need anything before we start?”
At the end of this phase of the interview, the patient should know the name of the primary nurse and what he or she can expect of nursing care, and should know what is expected of him or her in terms of developing the plan of care and participating in its execution.

The mental status examination assesses the function of the brain, mental functions, and behaviors. A good mental status examination helps assess many mental health or central nervous system disease states. A good mental status examination can be used over time to monitor a patient's severity of illness.

The first step in the mental status examination determines the patient's degree of arousal. Is the patient alert, sleepy, attentive, or unresponsive? Is the patient-oriented to person, place, and time, or is the patient confused?

How does the patient look? Is the patient well groomed? Is eye contact appropriate? Note poor hygiene, inappropriate dress, and lack of concern for appearance. Poor grooming indicates a potential psychiatric problem. Stooped posture and poor eye contact suggest depression. Colorful clothes or unusual clothing suggest a manic state.

Assess behavior and motor activity. Is the patient calm and relaxed, or is there any indication of restlessness, agitation, or lethargy? Note abnormal motor movements such as unusual facial expressions, tremors, or tics. Tremors or tics suggest a neurological disease, medication side effect, or anxiety. Excessive body movements suggest mania, anxiety, or stimulants. Repeated motor movements suggest obsessive-compulsive disorder. Minimal body movement may be depression, catatonic schizophrenia, or drug abuse.

Evaluate the mood and affect. Asking patients how they are feeling is a simple way to assess mood. Is the patient's emotional response to the situation appropriate? Observe the verbal or non-verbal behaviors to determine mood. Mood disturbances may be demonstrated by inappropriate feelings or behavior toward the situation. Note euphoria, agitation, depressed mood, flat affect, anxiety, labiality (shifting from one affect to another rapidly), irritability, excessive rage, indifference, carelessness, inability to sense emotions, and lack of sympathy.

The speech pattern is an important part of the psychosocial assessment. The patient's voice should be clear, strong, fluent, and articulate with a clear expression of thought. Note any of the following abnormalities in speech.

• Slurred speech
• Soft speech
• Loud speech
• Pressured speech
• Limited interaction
• Incoherent speech
• Halting speech
• Rapid speech

The slurring of words suggests intoxication. Pressured speech is seen in mania. Those with depression often have speech poverty. Note the patient's attitude. Is the patient cooperative, uncooperative, guarded, suspicious, or hostile?

The thought process is self-expressed by individuals and is observed through speech. It is not the content of the speech but the patterns of verbalization. It may range from normal to any of the terms in Table 2. A normal thought process is logical, relevant, sequential, and coherent.

Thought content is the theme that occupies the patient's thoughts and shows how coherent and logical the individual thinks. Disorders that suggest abnormalities include phobias, hypochondriasis, obsessive thought, hallucination, delusions, or other preoccupations.

Phobias are a morbid fear along with extreme anxiety. Hypochondriasis is the obsession with the idea of having a serious or life-threatening disease that is not diagnosed. Obsessive thoughts are unwelcome ideas, impulses, or emotions continually forced into the conscious mind. Hallucinations are something that the patient perceives but is not real. Hallucinations are suggested in those who hear voices, see images, feel bugs crawling on the skin, or smell offensive odors without evidence of them being present. Inquire about any command-type hallucinations and what the patient is commanded to do. Find out if the patient complies or is considering complying with the command.

Assess the patient for specific delusions and hallucinations. Table 3 gives questions to ask to determine if the patient is hallucinating or having delusions. Delusions are classified in multiple ways (see Table 4).

Impulse control can be assessed by asking the patient if they do activities without planning or thinking about them. Those who have poor impulse control have limited ability to resist temptation or the urge to do something that may be harmful to themselves or others. Many disorders are linked to poor impulse control, such as substance abuse, antisocial personality disorder, bipolar disease, schizophrenia, and impulse control disorder. Behaviors noted in those with poor impulse control include pathological gambling, excessive substance use or abuse, aggression, binge eating, and excessive, unsafe sexual behavior.

Judgment can be assessed by asking a made-up scenario to determine if there is an appropriate response. For example, what should you do if there is a fire in a crowded theater? Doing nothing would suggest poor judgment. Calling 911 or getting help suggests good responses. Other methods to assess judgment include looking at the patient's lifestyle. Poor judgment is likely to present in those involved in illegal activity or relationships with destructive ones. Judgment is impaired in schizophrenic, psychotic, intoxicated, manic, in some personality disorders or with a low intelligence quotient.

Assessment of cognition can be as simple as evaluating how the patient responds to questions asked during the assessment. More specific questions may be asked to provide a detailed analysis of the patient's cognitive ability. The Mini-Mental State Examination is a common way to assess cognition.

The first part of a cognitive assessment is determining if the patient is oriented to person, place, and time. Attention is the ability to focus, direct thinking, and not get distracted. Concentration is the ability to maintain attention over a while. A patient who cannot maintain attention will have other cognitive performance problems, especially executive function and memory, making a full mental status challenge assessment.

Lack of attention will be demonstrated by patients who lose their train of thought, become easily distracted, or ramble. Attention can be assessed by having the patient repeat a string of digits. An adult should be able to repeat 5-9 digits. Another way to assess attention includes having a patient spell a word backward (W-O-R-L-D is often used) or repeat the year's months in reverse order. Those with a demonstrated attention deficit may have a toxic metabolic encephalopathy or an acute psychiatric disorder.

The assessment of memory is the next step in the mental status examination. The immediate memory is tested by asking the patient to repeat a string of digits or asking the patient the time and place, or asking about recent events.

Another recent memory test involves telling the patient three words and then having the patient repeat the three words. After being distracted by another task, ask the patient to repeat the words five minutes later. A normal adult can remember all three words after five minutes. Offering the patient clues to help them remember can be done to assess the degree of memory impairment. Remote memory can be tested by asking about personal life events or important historical events, such as the states' names in reverse order.

The speech content is assessed by noting the presence or absence of any language errors during the speech. Naming is assessed by having the patient name objects shown to them. Show the patient three objects, such as a pencil, watch, and apple, and make sure they can name them. Reading and writing are assessed by having patients read a section of words and write a sentence. Repetition is assessed by having a patient repeat a common phrase.

Visual-spatial perception is assessed by having the patient copy an object (such as overlapping pentagons (Table 5), drawing an object, or building something. Having the patient draw a clock and telling them to make a certain time on the clock is another tool to assess visual-spatial perception. This test is often used as a screening test for dementia. Individuals with visual-spatial perception deficits may have difficulty navigation, get lost frequently, or often lose objects.

Praxis is learned motor movements and is demonstrated by the patient's ability to perform learning, skilled motor movements such as feeding or dressing. Praxis is assessed by the patient being given a stepwise series of coordinated tasks. It can be demonstrated by asking a patient to take a piece of paper, fold it in half, put it in an envelope, and hand it to the examiner. Apraxia can be seen in corticobasal degeneration.

Assessing the patient's ability to calculate is done by having the patient perform simple mathematical problems. Calculation assessment can be done by having the patient start at 100 and subtract seven serially (100, 93, 86, 79, 72, 65). The ability to perform this test is affected by educational and anxiety levels.

Executive function is a set of mental abilities synchronized in the brain's frontal lobe and helps people accomplish goals. It is hard to assess from the exam alone. It may take a good history from the patient and family or neuropsychological testing to fully assess executive function. It includes organizing, planning, remembering details, switching focus, managing time, suppressing inappropriate behavior or speech, and merging past experiences with present action. Individuals who have impaired executive function may not be able to function independently. Executive dysfunction can be seen in dementia, head injuries, strokes, depression, attention deficit disorder, or learning disabilities.

The executive function is assessed in the history part of the exam when determining if a patient can function well in everyday life. Patients who demonstrate problems with judgment or insight may have executive dysfunction. Abstract reasoning can be used to assess executive function. Can the patient explain a proverb such as, "a rolling stone gathers no moss"? Can the patient describe an idiom, or can a patient interpret differences and similarities like child or dwarf?

Some clinicians will determine estimated intelligence and general fund of knowledge; more extensive testing is required to do this accurately. It is best left for more advanced assessment, such as neuropsychological testing.

Mental status examinations are often done with standardized assessment tools. Standardized tests are helpful because they can follow a patient over time and can be done by many healthcare providers with similar results.