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The assessment may include but is not limited to, the following aspects: environmental, physical, cultural, psychological, safety, and psychosocial assessments.
The following is a guideline of what should happen during the assessment phase.
Data Collection:
During the assessment phase, the nurse collects objective and subjective data using proven methods to assess the patient. The most common methods for collecting data are the patient interview, physical examination, and observation.The patient interview is a deliberate or intended communication or conversation with the patient. It is used to obtain information, identify problems that concern the patient and/or the nurse, evaluate changes, provide support, and educate the patient and family/caregivers.
The nurse will also conduct a head-to-toe nursing assessment addressing each body system and noting any abnormalities, complaints, or concerns. Observation requires the nurse to use all their senses [sight, touch, smell, hearing] to learn about the patient.
Organize and Validate Data:
After collecting data, the nurse must organize and validate data and document about the patient's health status. Validation is the process of verifying data to be sure it is factual and accurate. Nurses must be careful to not come to conclusions without adequate data to support their conclusion.It is also necessary to understand the difference between inferences and cues. Cues are signals the patient uses to alert the nurse about a concern or question or objective data the nurse can observe or measure. Inferences are the nurse's conclusion or interpretation based on cues.
For example, the patient may complain about a painful incision two days post-operatively, and the nurse may observe the incision site is red and feels hot. These are cues. The nurse then makes an inference that the operative incision is infected.
Documenting Data:
After data from the assessment is collected, organized, and validated, it must be recorded. One thing I always tell nursing students and cannot stress enough to any nurse is, "If you didn't document it, you didn't do it." While that may seem harsh, from a legal standpoint, if a nurse is asked to verify care or treatment and there is no supporting documentation, there is no way to prove the care occurred.Thorough documentation is one of the best ways for everyone involved in patient care to be aware of changes in the patient's status, and it helps promote effective collaboration within the interdisciplinary team.
5 Common Challenges You Will Face During the Assessment Phase And How To Overcome
While all the nursing process steps are essential, without a thorough assessment, the other steps of the nursing process are not as easy to follow through. Nurses must recognize barriers that could impede the assessment phase and find ways to overcome them. The following are five common challenges you may face during the assessment phase and some suggestions on how to overcome them.Challenge #1: Limited Time
About the Challenge:There are days when nurses feel as though there aren’t enough hours to accomplish all the work that needs to be done. When you are short-staffed or have several patients waiting for a nursing assessment before you can initiate care, it can feel a bit overwhelming.How to Overcome:Even on the busiest of days, it is important for nurses to perform thorough nursing assessments for all patients assigned to them. That means it is necessary to learn to manage time efficiently. The first step in overcoming limited time is to be familiar with the format or forms your employer uses to record assessments.For example, the Health Information Technology for Economic and Clinical Health Act of 2009 advanced the adoption and use of electronic health records. Nearly one hundred percent of hospitals use some type of EHR. Electronic health records have helped improve workflow by eliminating time spent pulling physical charts or documenting in paper charts.
Challenge #2: Interruptions
About the Challenge:It is not uncommon for interruptions to occur when nurses are performing assessments. While some interruptions may be necessary, all are not. Interruptions during patient assessments can delay care and could result in errors or omissions.How to Overcome:The best way to overcome the challenge of interruptions during the assessment step of the nursing process is to provide for privacy before you begin the assessment.Whether you are working in triage, assessing a patient newly admitted to your floor, or in a busy emergency room, it is possible to reduce interruption. Pull the privacy curtain closed if you are in an area with more than one patient or several staff close by. Some facilities use "Do Not Disturb" or "Room in Use" signs to provide privacy for nurses and patients.
Challenge #3: Inexperience
About the Challenge:Every nurse knows the importance of a good nursing assessment. Newly graduated nurses are less experienced than other nurses and may feel uneasy about performing a nursing assessment alone. Additionally, if your facility changes its documentation format or implements a new program for charting, and you've not yet used the program, your inexperience could pose a challenge when doing an assessment.How to Overcome:The only way to overcome inexperience is to become experienced. Nursing assessments are typically classified as either a Complete Health Assessment or a Problem-Focused Assessment. Know which type of assessment you need to perform.Gather basic equipment: gloves, thermometer, blood pressure cuff, stethoscope, penlight, and watch. Establish a sense of trust and respect between the patient and yourself.
No matter which type of assessment you perform, it should be systematic, making sure you cover each body system. If you assess each body system and make notes about what is normal/abnormal, you decrease the chances of omissions in documentation. Remember, take your time, trust your instincts, and if you need help, ask for it.
Challenge #4: Patient Anxiety
About the Challenge:Patient anxiety can create a significant challenge for nurses during a patient assessment. Anxiety can hinder communication making it difficult to gather all the necessary data. If anxiety is bad enough, it can cause changes in vital signs, which could be misinterpreted as something more than an anxious reaction.How to Overcome:Before beginning an assessment, take the time to make your patient comfortable. While you may not have time for a long conversation or "get to know you" session, you can ease your patient's anxiety by being calm and friendly.Some questions may make patients feel uncomfortable, especially teenagers. Allow them time to answer your questions without feeling rushed. Verify their understanding by asking if they can explain what you've discussed in their own words.
Remember, everyone gets nervous or anxious at times, and when we are sick, it can be worse. It's nothing personal against you or your skills. Make everything about the patient.
Challenge #5: Patients Not Being Forthcoming About Symptoms
About the Challenge:Whether it is fear of the unknown, embarrassment, or another reason, there are times when patients may be apprehensive about sharing personal information.Lack of information or omission of details that the patient may think is irrelevant may negatively impact the process of care planning. Therefore, while it is easy to understand a patient's apprehension, it is crucial for nurses to gather as much information as possible when performing a nursing assessment.
How to Overcome:It can be easy to feel frustrated if a patient is not forthcoming about symptoms during an assessment. Keep in mind, being sick and needing medical care can be frightening.The best way to get patients to talk to you is to be accepting of them, no matter what. Be sure to tell your patient you are there for them and will work with them to help them get better. When you say things like you will "work with them," it lets your patient know you are going to do your part, but you expect them to do theirs as well.
If you feel like your patient is withholding information, instead of making an accusation, try to rephrase the question. Make your questions clear so the patient knows what information you need.
Real-World Example Of The Assessment Phase
The format for recording nursing assessment data may vary from one facility to another. However, the information gathered for the assessment is relatively similar. The following are examples of content the nurse should include in the initial nursing assessment phase of the nursing process.Admission Notes
Date of Admission: 04/19/22 Time: 13.30Transported By: J. Mock, LPN
Age: 54 yrs. 2 mos. Sex: M Height: 6’2” Weight: 268lbs 4oz
Attending Physician: Dr. Michael Coulvan
Date of Birth: 03/04/1968
Admitting Diagnosis: CHF, acute
Vital Signs on Admission: Temp 98.8, Resp. 20, Pulse 76, BP 136/80
Allergies: NKDA, no food allergies
Patient Demographics
Patient Name: Jerold R. CollieAddress: 123 Blakely Lane, Clayton, MO. 1234
Phone: [318] 555-1234
Physical Assessment
• Neurological: Alert & Oriented x3; PERRLA, Unaided hearing; Bilateral hand grips equal; Bilateral foot push equal; no evidence of tremors; denies tingling, burning, loss of consciousness, hallucinations, disorientation, visual disturbances, or hx/o brain injury or stroke.• Cardiovascular: Pulses present, regular, and strong: x2 upper extremities [Radial]; present X2 lower extremities [Pedal]; heart rate regular, strong; capillary refill