10 Assessing

LEA R NIN G OU TC OME S

After completing this chapter, you will be able to:
1. Describe the phases of the nursing process. 6. Identify three methods of data collection, and give examples
2. Identify major characteristics of the nursing process. of how each is useful.
3. Identify the purpose of assessing. 7. Compare directive and nondirective approaches to interviewing.
4. Identify the four major activities associated with the assessing 8. Compare closed and open-ended questions, providing exam-
phase. ples and listing advantages and disadvantages of each.
5. Differentiate objective and subjective data and primary and 9. Describe important aspects of the interview setting.
secondary data. 10. Contrast various frameworks used for nursing assessment.

K EY T ER M S
assessing, 195 directive interview, 200 nondirective interview, 200 screening examination, 204
cephalocaudal, 204 focused interview, 200 nursing process, 190 signs, 198
closed questions, 200 inferences, 208 objective data, 198 subjective data, 198
cues, 208 interview, 200 open-ended questions, 201 symptoms, 198
data, 195 leading question, 201 rapport, 200 validation, 208
database, 196 neutral question, 201 review of systems, 204

Introduction Phases of the Nursing Process

The nursing process is a systematic, rational method The Standards of Practice within the most current Scope
of planning and providing individualized nursing and Standards of Nursing Practice include six phases of the
care. Its purposes are to identify a client’s health status nursing process: assessment, diagnosis, outcomes identi-
and actual or potential healthcare problems or needs, fication, planning, implementation, and evaluation (ANA,
to establish plans to meet the identified needs, and to 2015). The national licensure examination for registered
deliver specific nursing interventions to meet those nurses (NCLEX) uses five phases: assessment, analysis,
needs. The client may be an individual, a family, a com- planning, implementing, and evaluation. This text, and
munity, or a group. most others, uses five phases: assessing, diagnosing
Hall originated the term nursing process in 1955, and (which includes outcomes identification and analysis),
Johnson (1959), Orlando (1961), and Wiedenbach (1963) planning, implementing, and evaluating. Although nurses
were among the first to use it to refer to a series of phases may use different terms to describe the phases (or steps)
describing the practice of nursing. Since then, various of the nursing process, the activities of the nurse using
nurses have described the process of nursing and orga- the process are similar. For example, implementing may be
nized the phases in different ways. called implementation, intervention, or intervening.
An overview of the five-phase nursing process is
shown in Table 10.1. Each of the five phases is discussed
in depth in this and subsequent chapters of this unit. The
Overview of the Nursing phases of the nursing process are not separate entities but
Process overlapping, continuing subprocesses (Figure 10.2 ■). For
example, assessing, which may be considered the first
The use of the nursing process in clinical practice gained phase of the nursing process, is also carried out during the
additional legitimacy in 1973 when the phases were implementing and evaluating phases. For instance, while
included in the American Nurses Association (ANA) actually administering medications (implementing), the
Standards of Nursing Practice. Figure 10.1 ■ illustrates the nurse continuously notes the client’s skin color, level of
nursing process in action. consciousness, and so on.

190

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 Chapter 10 • Assessing 191

TABLE 10.1 Overview of the Nursing Process

Phase and Description Purpose Activities
ASSESSING
Collecting, organizing, validating, and docu- To establish a database about the client’s Establish a database:
menting client data response to health concerns or illness and • Obtain a nursing health history.
the ability to manage healthcare needs • Conduct a physical assessment.
• Review client records.
• Review nursing literature.
• Consult support persons.
• Consult health professionals.
Update data as needed.
Organize data.
Validate data.
Communicate and document data.
DIAGNOSING
Analyzing and synthesizing data To identify client strengths and health prob- Interpret and analyze data:
lems that can be prevented or resolved • Compare data against standards.
by collaborative and independent nursing • Cluster or group data (generate tentative
interventions hypotheses).
To develop a list of nursing and collabora- • Identify gaps and inconsistencies.
tive problems Determine client’s strengths, risks, and
problems.
Formulate nursing diagnoses and collabora-
tive problem statements.
Document nursing diagnoses on the care
plan.
PLANNING
Determining how to prevent, reduce, or To develop an individualized care plan that Set priorities and goals or desired out-
resolve the identified priority client problems; specifies client goals or desired outcomes comes in collaboration with client.
how to support client strengths; and how and related nursing interventions Write goals or desired outcomes.
to implement nursing interventions in an Select nursing strategies and interventions.
organized, individualized, and goal-directed Consult other health professionals.
manner Write nursing interventions and nursing care
plan.
Communicate care plan to relevant health-
care providers.
IMPLEMENTING
Carrying out (or delegating) and document- To assist the client to meet desired goals Reassess the client to update the database.
ing the planned nursing interventions or outcomes; promote wellness; prevent ill- Determine the nurse’s need for assistance.
ness and disease; restore health; and facili- Perform planned nursing interventions.
tate coping with altered functioning Communicate what nursing actions were
implemented:
• Document care and client responses to
care.
• Give verbal reports as necessary.
EVALUATING
Measuring the degree to which goals or To determine whether to continue, modify, Collaborate with client and collect data
outcomes have been achieved and identify- or terminate the plan of care related to desired outcomes.
ing factors that positively or negatively Judge whether goals or outcomes have
influence goal achievement been achieved.
Relate nursing actions to client goals or
outcomes.
Make decisions about problem status.
Review and modify the care plan as indi-
cated or terminate nursing care.
Document achievement of outcomes and
modification of the care plan.

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 192 Unit 3 • The Nursing Process

The nursing process is a systematic,

rational method of planning and
providing nursing care. Its purpose is to
identify a client’s healthcare status, and
ASSESSING
actual or potential health problems, to
• Collect data
establish plans to meet the identified ASSESSING • Organize data
needs, and to deliver specific nursing • Validate data
interventions to address those needs. • Document data
The nursing process is cyclical; that
is, its components follow a logical
sequence, but more than one
component may be involved at
one time. At the end of the DIAGNOSING
DIAGNOSING • Analyze data
first cycle, care may be
• Identify health problems,
terminated if goals are
risks, and strengths
achieved, or the cycle • Formulate diagnostic
may continue with statements
reassessment, or the
plan of care may be
modified.
PLANNING
PLANNING • Prioritize problems/diagnoses
• Formulate goals/desired outcomes
• Select nursing interventions
• Write nursing interventions

IMPLEMENTING IMPLEMENTING
• Reassess the client
• Determine the nurse’s need for assistance
• Implement the nursing interventions
• Supervise delegated care
• Document nursing activities
EVALUATING
EVALUATING
• Collect data related to outcomes
• Compare data with outcomes
• Relate nursing actions to client goals/outcomes
• Draw conclusions about problem status
• Continue, modify, or terminate the client’s care plan
Figure 10.1 ■ The nursing process in action.

Each phase of the nursing process affects the others; dynamic nature, client centeredness, focus on problem-
they are closely interrelated. For example, if inadequate data solving and decision-making, interpersonal and collab-
are obtained during assessing, the nursing diagnoses will be orative style, universal applicability, and use of critical
incomplete or incorrect; inaccuracy will also be reflected in thinking and clinical reasoning.
the planning, implementing, and evaluating phases.
• Data from each phase provide input into the next
phase. Findings from the evaluation phase feed back
Characteristics of the Nursing Process into assessment. Hence, the nursing process is a regu-
The nursing process has distinctive characteristics that larly repeated event or sequence of events (a cycle) that
enable the nurse to respond to the changing health status is continuously changing (dynamic) rather than staying
of the client. These characteristics include its cyclic and the same (static).

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 Chapter 10 • Assessing 193

Margaret O’Brien is a 33-year-old

nursing student. She is married and ASSESSING Nurse Medina’s physical
has a 13-year-old daughter and assessment reveals that Margaret’s vital
5-year-old son. She is admitted to signs are: Temperature, 39.4°C (103°F);
the hospital with an elevated pulse 92 beats/min; respirations 28/min;
temperature, a productive cough, and blood pressure, 122/80 mmHg. Nurse
Medina observes that Margaret’s skin is
and rapid, labored respirations. dry, her cheeks are flushed, and she is
While taking a nursing history, experiencing chills. Auscultation reveals
Mary Medina, RN, finds that inspiratory crackles with diminished breath
Margaret has had a “chest cold” for sounds in the right lung.
2 weeks and has been
experiencing shortness of
breath upon exertion. DIAGNOSING After analysis,
Nurse Medina formulates a
Yesterday she developed an
nursing diagnosis: altered
elevated temperature and respiratory status related to
began to experience accumulated mucus
“pain” in her “lungs.” obstructing airways.

PLANNING Nurse Medina and

Margaret collaborate to establish goals
(e.g., restore effective breathing pattern
and lung ventilation); set outcome
criteria (e.g., have a symmetrical
respiratory excursion of at least 4 cm,
and so on); and develop a care plan
that includes, but is not limited to,
coughing and deep-breathing exercises
q3h, fluid intake of 3000 mL daily, and
daily postural drainage.

IMPLEMENTING Margaret agrees to practice the

deep-breathing exercises q3h during the day. In
addition, she verbalizes awareness of the need to
increase her fluid intake and to plan her morning
activities to accommodate postural drainage.

EVALUATING Upon assessment of

respiratory excursion, Nurse Medina
detects failure of the client to achieve
maximum ventilation. She and Margaret
re-evaluate the care plan and modify it to
increase coughing and deep-breathing
exercises to q2h.

Figure 10.1 ■ Continued

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 194 Unit 3 • The Nursing Process

Examples of Critical Thinking

TABLE 10.2 in the Nursing Process
Nursing
Process
Assessing Phase Critical Thinking Activities

Diagnosing Assessing Making reliable observations

Distinguishing relevant from irrelevant data
Distinguishing important from unimportant data
Validating data
Critical
Evaluating Thinking Organizing data
Categorizing data according to a framework
Recognizing assumptions
Planning
Identifying gaps in the data
Diagnosing Finding patterns and relationships among cues
Implementing Making inferences
Suspending judgment when lacking data
Stating the problem
Examining assumptions
Comparing patterns with norms
Figure 10.2 ■ The five overlapping phases of the nursing process.
Identifying factors contributing to the problem
Each phase depends on the accuracy of the other phases. Each phase
involves critical thinking. Planning Forming valid generalizations
Transferring knowledge from one situation to
another
Developing evaluative criteria
• The nursing process is client centered. The nurse Hypothesizing
organizes the plan of care according to client prob-
Making interdisciplinary connections
lems rather than nursing goals. In the assessment
phase, the nurse collects data to determine the cli- Prioritizing client problems
ent’s habits, routines, and needs, enabling the nurse Generalizing principles from other sciences
to incorporate client routines into the care plan as Implementing Applying knowledge to perform interventions
much as possible. Testing hypotheses
• The nursing process is an adaptation of problem-­
Evaluating Deciding whether hypotheses are correct
solving (see Chapter 9 ) and systems theory (see
Making criterion-based evaluations
Chapter 27 ). It can be viewed as parallel to but sepa-
From Nursing Process and Critical Thinking, 5th ed. (pp. 59–61), by J. M. Wilkinson, 2012,
rate from the process used by physicians (the medical Upper Saddle River, NJ: Pearson.
model). Both processes (a) begin with data gathering
and analysis, (b) base action (intervention or treatment)
on a problem statement (nursing diagnosis or medical
diagnosis), and (c) include an evaluative component. of the healthcare team, in a joint effort to provide qual-
However, the medical model focuses on physiologic ity client care.
systems and the disease process, whereas the nursing • The universally applicable characteristic of the nursing
process is directed toward a client’s responses to real or process means that it is used as a framework for nurs-
potential disease and illness. ing care in all types of healthcare settings, with clients
• Decision-making is involved in every phase of the nurs- of all age groups.
ing process. Nurses can be highly creative in determin- • Nurses must use a variety of critical thinking skills
ing when and how to use data to make decisions. They to carry out the nursing process (see Chapter 9 ).
are not bound by standard responses and may apply Table 10.2 provides examples of critical thinking in the
their repertoire of skills and knowledge to assist clients. nursing process.
This facilitates the individualization of the nurse’s plan • Nurses must utilize clinical reasoning throughout the
of care. delivery of nursing care. By reflecting, the nurse deter-
• The nursing process is interpersonal and collaborative. mines whether the outcome of care was appropriate.
It requires the nurse to communicate directly and con- Figure 10.3 ■ provides an overview of the nursing pro-
sistently with clients and families to meet their needs. cess and reflection questions to be asked by the nurse
It also requires that nurses collaborate, as members while providing and evaluating care.

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 Chapter 10 • Assessing 195

Assessing
Gather subjective and
objective data
Identify the client's chief
Reflecting complaint

Was care provided in a

Diagnosing
timely manner?
Was the client assessed Based on the data
accurately? collected identify a
nursing diagnosis
Were the interventions
appropriate? Consult evidence-based
practice literature
Were the goals attained?
Was the nursing
diagnosis resolved?
Critical Thinking
Clinical Reasoning
Nursing Process

Planning
Goal development
Evaluating Recall nursing and health
Evaluate the client's related knowledge
response to the care Consult with the primary
provided care provider and client
Review outcomes of prior
clinical situations
Implementing
Identify and implement
interventions to assist in
the attainment of goals
and resolution of the
nursing diagnosis

Figure 10.3 ■ Critical thinking, clinical reasoning, and the nursing process.

Assessing Nursing assessments focus on a client’s responses to a

health problem. A nursing assessment should include the
Assessing is the systematic and continuous collection, client’s perceived needs, health problems, related expe-
organization, validation, and documentation of data rience, health practices, values, and lifestyle. To be most
(information) (Figure 10.4 ■). In effect, assessing is a useful, the data collected should be relevant to a particular
continuous process carried out during all phases of the health problem. Therefore, nurses should think critically
nursing process. For example, in the evaluation phase, about what to assess. In 2008, The Joint Commission estab-
the client is reassessed to determine the outcomes of the lished a nursing practice guideline stating that each client
nursing strategies and to evaluate goal achievement. should have an initial nursing assessment consisting of a
All phases of the nursing process depend on the accu- history and physical examination performed and docu-
rate and complete collection of data. The four different mented within 24 hours of admission as an inpatient. This
types of assessments are the initial nursing assessment, assessment guideline remains in effect today. The guide-
problem-focused assessment, emergency assessment, and line states further that a licensed practical nurse (LPN) may
time-lapsed reassessment (Table 10.3). Assessments vary gather the data but the registered nurse (RN) is responsible
according to their purpose, timing, time available, and for care and must assess the data determining the needs of
client status. the client. The RN also has the responsibility for developing

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 196 Unit 3 • The Nursing Process

The ANA Standard 1: Assessment (2015) states the

RN is responsible for the collection of pertinent data,
including demographics, social determinants of health,
health disparities, and physical, functional, psychosocial,
Assessing emotional, cognitive, sexual, cultural, age-related, envi-
• Collect data
• Organize data
ronmental, spiritual, transpersonal, and economic assess-
• Validate data ments. Data should be collected in a systematic way and
• Document data be ongoing with compassion and respect for the inherent
dignity, worth, and unique attributes of every individual
(ANA, 2015, p. 52). ANA also recognizes the importance
Diagnosing
of the assessment of clients based on the parameters out-
lined by Healthy People 2020. It is also important to assess
the client’s values, attitudes, beliefs, and family dynamics.

Collecting Data
Evaluating

Data collection is the process of gathering information

Planning
about a client’s health status. Data collection must be
both systematic and continuous to prevent the omission
Implementing of significant data and reflect a client’s changing health
status.
A database contains all the information about a client;
it includes the nursing health history (Box 10.1), physical
assessment, primary care provider’s history and physical
examination, results of laboratory and diagnostic tests,
Figure 10.4 ■ Assessing. The assessment process involves four and material contributed by other health personnel.
closely related activities.
Client data should include past history as well as cur-
rent problems. For example, a history of an allergic reac-
the client’s plan of care. In regards to the use of scribes to tion to penicillin is a vital piece of historical data. Past
gather subjective data, The Joint Commission (2019) does surgical procedures, folk healing practices, and chronic
not endorse or prohibit scribes. However, there must be diseases are also examples of historical data. Current data
a sufficient orientation and training that is specific to the relate to present circumstances, such as pain, nausea, sleep
scribe’s role and the organization. The licensed practitioner patterns, and religious practices. To collect data accu-
or physician must authenticate the information, and it must rately, both the client and nurse must actively participate.
be signed and dated by the practitioner. Data can be of the subjective or objective and constant or

TABLE 10.3 Types of Assessment

Type Time Performed Purpose Example
Initial assessment Performed within specified time To establish a complete Nursing admission assessment
after admission to a healthcare database for problem identi-
agency fication, reference, and future
comparison
Problem-focused assessment Ongoing process integrated To determine the status of a Hourly assessment of client’s
with nursing care specific problem identified in an fluid intake and urinary output in
earlier assessment an intensive care unit (ICU)
Assessment of client’s ability to
perform self-care while assisting
a client to bathe
Emergency assessment During any physiologic or psy- To identify life-threatening Rapid assessment of an individu-
chologic crisis of the client problems al’s airway, breathing status, and
To identify new or overlooked circulation during a cardiac arrest
problems Assessment of suicidal tenden-
cies or potential for violence
Time-lapsed reassessment Several months after initial To compare the client’s current Reassessment of a client’s func-
assessment status to baseline data previ- tional health patterns in a home
ously obtained care or outpatient setting or, in a
hospital, at shift change

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 Chapter 10 • Assessing 197

BOX 10.1 Components of a Nursing Health History

BIOGRAPHIC DATA • Activities of daily living (ADLs): any difficulties experienced in the
Client’s name, address, age, sex, marital status, occupation, reli- basic activities of eating, grooming, dressing, elimination, and
gious preference, healthcare financing, and usual source of medical locomotion
care. • Instrumental ADLs: any difficulties experienced in food prepa-
ration, shopping, transportation, housekeeping, laundry, and
CHIEF COMPLAINT OR REASON FOR VISIT
ability to use the telephone, handle finances, and manage
The answer given to the question “What is troubling you?” or medications
“Describe the reason you came to the hospital or clinic today.” The • Recreation and hobbies: exercise activity and tolerance, hob-
chief complaint should be recorded in the client’s own words.
bies and other interests, and vacations
History of Present Illness
• When the symptoms started SOCIAL DATA
• Whether the onset of symptoms was sudden or gradual • Family relationships and friendships: the client’s support system
• How often the problem occurs in times of stress (who helps in time of need?), what effect the
client’s illness has on the family, and whether any family prob-
• Exact location of the distress
lems are affecting the client (see also the discussion of family
• Character of the complaint (e.g., intensity of pain or quality of assessment in Chapter 27 )
sputum, emesis, or discharge)
• Ethnic affiliation: health customs and beliefs; cultural practices
• Activity in which the client was involved when the problem that may affect healthcare and recovery (see also the detailed
occurred ethnic and cultural assessment guide in Chapter 21 )
• Phenomena or symptoms associated with the chief complaint • Educational history: data about the client’s highest level of edu-
• Factors that aggravate or alleviate the problem cation attained and any past difficulties with learning
• Occupational history: current employment status, the number
PAST HISTORY of days missed from work because of illness, any history of
• Illnesses, such as chickenpox, mumps, measles, rubella (Ger- accidents on the job, any occupational hazards with a potential
man measles), rubeola (red measles), streptococcal infections, for future disease or accident, the client’s need to change jobs
scarlet fever, rheumatic fever, hepatitis, polio, and other signifi- because of past illness, the employment status of spouses or
cant illnesses partners and the way child care is handled, and the client’s
• Immunizations and the date of the last tetanus shot overall satisfaction with the work
• Allergies to drugs, animals, insects, or other environmental • Economic status: information about how the client is paying for
agents, the type of reaction that occurs, and how the reaction medical care (including what kind of medical and hospitalization
is treated coverage the client has) and whether the client’s illness pres-
• Accidents and injuries: how, when, and where the inci- ents financial concerns
dent occurred, type of injury, treatment received, and any • Home and neighborhood conditions: home safety measures
complications and adjustments in physical facilities that may be required to
• Hospitalization for serious illnesses: reasons for the hospitaliza- help the client manage a physical disability, activity intolerance,
tion, dates, surgery performed, course of recovery, and any and activities of daily living; the availability of neighborhood and
complications community services to meet the client’s needs
• Medications: all currently used prescription and over-the-
PSYCHOLOGIC DATA
counter medications, such as aspirin, nasal spray, vitamins,
laxatives, and herbal supplements • Major stressors experienced and the client’s perception of
them
FAMILY HISTORY OF ILLNESS • Usual coping pattern for a serious problem or a high level of

To ascertain risk factors for certain diseases, the ages of siblings, stress
parents, and grandparents and their current state of health, or, if they • Communication style: ability to verbalize appropriate emo-
are deceased, the cause of death, are obtained. Particular attention tion; nonverbal communication—such as eye movements,
should be given to disorders such as heart disease, cancer, diabe- gestures, use of touch, and posture; interactions with support
tes, hypertension, obesity, allergies, arthritis, tuberculosis, bleeding, persons; and the congruence of nonverbal behavior and verbal
alcoholism, and any mental health disorders. expression
LIFESTYLE
PATTERNS OF HEALTHCARE
• Personal habits: the amount, frequency, and duration of sub-
All healthcare resources the client is currently using and has used in
stance use (tobacco, alcohol, coffee, cola, tea, and illegal or
the past. These include the primary care provider, specialists (e.g.,
recreational drugs)
ophthalmologist or gynecologist), dentist, folk practitioners (e.g.,
• Diet: description of a typical diet on a normal day or any special
herbalist or curandero), health clinic, or health center; whether the
diet, number of meals and snacks per day, who cooks and client considers the care being provided adequate; and whether
shops for food, ethnic food patterns, and allergies access to healthcare is a problem.
• Sleep patterns: usual daily sleep and wake times, difficulties
sleeping, and remedies used for difficulties

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 198 Unit 3 • The Nursing Process

TABLE 10.4 Examples of Subjective and Objective Data

Subjective Objective
“I feel weak all over when I exert myself.” Blood pressure 90/50 mmHg*
Apical pulse 104 beats/min
Skin pale and diaphoretic
Client states he has a cramping pain in his abdomen. States, “I feel Vomited 100 mL green-tinged fluid
sick to my stomach.” Abdomen firm and slightly distended
Active bowel sounds auscultated in all four quadrants
“I’m short of breath.” Lung sounds clear bilaterally; diminished in right lower lobe
Wife states: “He doesn’t seem so sad today.” (This is subjective Client cried during interview
and secondary source data.)
“I would like to see the chaplain before surgery.” Holding open Bible
Has small silver cross on bedside table
*Blood pressure obtained using an external cuff and manometer may be considered secondary or indirect data since it does not directly measure the pressure within the arteries.

variable types, and from a primary or secondary source. In fact, all sources other than the client are considered
The collection of data allows the nurse, client, and health- secondary sources. All data from secondary sources
care team to identify health-related problems or risk fac- should be validated if possible.
tors that could cause changes in a client’s health status.
Client
The best source of data is usually the client, unless the client
Types of Data is too ill, young, or confused to communicate clearly. The
Subjective data, also referred to as symptoms or covert nurse is often much closer to the client than other members
data, are apparent only to the individual affected and can of the healthcare team. In community and acute care set-
be described or verified only by that individual. Itching, tings, the nurse has the closest relationship with the client
pain, and feelings of worry are examples of subjective and family. It is important to develop strategies to build
data. Subjective data include the client’s sensations, feel- therapeutic relationships with the client and family. When
ings, values, beliefs, attitudes, and perception of personal establishing a rapport with the client it is important to share
health status and life situation. that, by gathering a thorough assessment, the nurse will be
Objective data, also referred to as signs or overt data, able to meet the needs of the client to ensure better health
are detectable by an observer or can be measured or tested outcomes. When developing a therapeutic relationship,
against an accepted standard. They can be seen, heard, Feo, Rasmussen, Wiechula, Conroy, and Kitson (2017) have
felt, or smelled, and they are obtained by observation or identified the following factors when focusing on provid-
physical examination. For example, a discoloration of the ing client care. The nurse should give the client undivided
skin or a blood pressure reading is objective data. During attention. The nurse should anticipate the client’s needs.
the physical examination, the nurse obtains objective data The nurse should inform the client of healthcare decisions
to validate subjective data and to complete the assessment and evaluate the quality of the relationship. The client can
phase of the nursing process. provide subjective data that no one else can offer. Most
Constant data is information that does not change often, primary data consist of statements made by the cli-
over time such as race or blood type. Variable data can ent but also include the objective data that can be directly
change quickly, frequently, or rarely and include such data obtained from the client, such as gender. Some clients can-
as blood pressure, level of pain, and age. not or do not wish to provide accurate data. Family mem-
A complete database provides a baseline for compar- bers or significant others can be secondary sources of data
ing the client’s responses to nursing and medical interven- if the client cannot participate, is a poor historian, or is a
tions. Examples of subjective and objective data are shown young child. If the client is hesitant to provide data, remind
in Table 10.4. the client that the privacy of all data collected is protected
and data can be shared only with individuals who have
legitimate health-related needs to know it. If necessary,
Sources of Data review for yourself the mandates of the Health Insurance
Sources of data are primary or secondary. The client is Portability and Accountability Act of 1996 (HIPAA) so you
the primary source of data. Family members or other can explain this in a way that the client can understand.
support persons, other health professionals, records Summarized information about HIPAA in terms under-
and reports, laboratory and diagnostic analyses, and standable to both nurses and clients is available on the U.S.
relevant literature are secondary or indirect sources. Department of Health and Human Services website.

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 Chapter 10 • Assessing 199

Support People Laboratory records also provide pertinent health

Family members, friends, and caregivers who know the information. For example, the determination of blood
client well often can supplement or verify information glucose level allows health professionals to monitor the
provided by the client. They might convey informa- administration of oral hypoglycemic medications. Any
tion about the client’s response to illness, the stresses laboratory data about a client must be compared to the
the client was experiencing before the illness, family agency or performing laboratory’s norms for that par-
attitudes on illness and health, and the client’s home ticular test and for the client’s age, gender, and other
environment. characteristics. Commonly ordered diagnostic studies are
Support people are an especially important source discussed in Chapter 34 .
of data for a client who is very young, unconscious, or The nurse must always consider the information in
confused. In some cases—a client who is physically or client records in light of the current situation. For example,
emotionally abused, for example—the individual giving if the most recent medical record is 10 years old, the cli-
information may wish to remain anonymous. Before elic- ent’s health practices and coping behaviors are likely to
iting data from support people, the nurse should ensure have changed. Older clients may have numerous previ-
that the client, if mentally able, authorizes such input. The ous records. These are very useful and contribute to a full
nurse should also indicate on the nursing history that the understanding of the health history, especially if the cli-
data were obtained from a support person. ent’s memory is impaired.
Information supplied by family members, significant
others, or other health professionals is considered subjec-
Healthcare Professionals
Because assessment is an ongoing process, verbal reports
tive if it is not based on fact. If the client’s daughter says,
from other healthcare professionals serve as other poten-
“Dad is very confused today,” that is secondary subjective
tial sources of information about a client’s health. Nurses,
data because it is an interpretation of the client’s behav-
social workers, primary care providers, and physiother-
ior by the daughter. The nurse should attempt to verify
apists, for example, may have information from either
the reported confusion by interviewing the client directly.
previous or current contact with the client. Sharing of
However, if the daughter says, “Dad said he thought it
information among professionals is especially important
was the year 1941 today,” that may be considered second-
to ensure continuity of care when clients are transferred
ary objective data since the daughter heard her father state
to and from home and healthcare agencies.
this directly.
Literature
Client Records The review of nursing and related literature, such as
Client records include information documented by vari- professional journals and reference texts, can provide
ous healthcare professionals. Client records also con- additional information for the database. A literature
tain data regarding the client’s occupation, religion, and review includes but is not limited to the following
marital status. By reviewing such records before inter- information:
viewing the client, the nurse can avoid asking ques-
tions for which answers have already been supplied. • Standards or norms against which to compare findings
Repeated questioning can be stressful and annoying to (e.g., height and weight tables, normal developmental
clients and cause concern about the lack of communica- tasks for an age group)
tion among health professionals. Types of client records • Cultural and social health practices
include medical records, records of therapies, and labo- • Spiritual beliefs
ratory records. • Assessment data needed for specific client conditions
Medical records (e.g., medical history, physical exam- • Nursing interventions and evaluation criteria relevant
ination, operative report, progress notes, and consulta- to a client’s health problems
tions done by primary care providers) are often a source • Information about medical diagnoses, treatment, and
of a client’s present and past health and illness patterns. prognoses
These records can provide nurses with information about • Current methodologies and research findings.
the client’s coping behaviors, health practices, previous
illnesses, and allergies.
Records of therapies provided by other health profes- Data Collection Methods
sionals, such as social workers, nutritionists, dietitians, or The principal methods used to collect data are observing,
physical therapists, help the nurse obtain relevant data interviewing, and examining. Observing occurs whenever
not expressed by the client. For example, a social agency’s the nurse is in contact with the client or support persons.
report on a client’s living conditions or a home healthcare Interviewing is used mainly while taking the nursing
agency’s report on a client’s ability to cope at home help health history. Examining is the major method used in the
the nurse conducting an assessment. physical health assessment.

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 200 Unit 3 • The Nursing Process

In reality, the nurse uses all three methods simulta- Nursing observations must be organized so that noth-
neously when assessing clients. For example, during the ing significant is missed. Most nurses develop a particular
client interview the nurse observes, listens, asks questions, sequence for observing events, usually focusing on the cli-
and mentally retains information to explore in the physi- ent first. For example, a nurse walks into a client’s room
cal examination. and observes, in the following order:

Observing 1. Clinical signs of client distress (e.g., pallor or flush-

To observe is to gather data by using the senses. Observing ing, labored breathing, and behavior indicating pain
is a conscious, deliberate skill that is developed through or emotional distress)
effort and with an organized approach. Although nurses 2. Threats to the client’s safety, real or anticipated (e.g.,
observe mainly through sight, most of the senses are a lowered side rail)
engaged during careful observations. Examples of client 3. The presence and functioning of associated equipment
data observed through the senses are shown in Table 10.5. (e.g., IV equipment and oxygen)
Observing has two aspects: (a) noticing the data and 4. The immediate environment, including the people in it.
(b) selecting, organizing, and interpreting the data. A nurse
who observes that a client’s face is flushed must relate Interviewing
that observation to findings such as body temperature, An interview is a planned communication or a conver-
activity, environmental temperature, and blood pressure. sation with a purpose, for example, to get or give infor-
Errors can occur in selecting, organizing, and interpret- mation, identify problems of mutual concern, evaluate
ing data. For example, a nurse might not notice certain change, teach, provide support, or provide counseling
signs, either because they are unexpected or because they or therapy. One example of the interview is the nursing
do not conform to preconceptions about a client’s illness. health history, which is a part of the nursing admission
Nurses often need to focus on specific data in order not to assessment. In a focused interview the nurse asks the client
be overwhelmed by a multitude of data. Observing, there- specific questions to collect information related to the cli-
fore, involves distinguishing data in a meaningful manner. ent’s problem. This allows the nurse to collect information
For example, nurses caring for newborns learn to ignore that may have previously been missed and yields more
the usual sounds of machines in the nursery but respond in-depth information (D’Amico & Barbarito, 2016).
quickly to an infant’s cry or movement. There are two approaches to interviewing: direc-
The experienced nurse is often able to attend to an tive and nondirective. The directive interview is highly
intervention (e.g., give a bed bath or monitor an IV infu- structured and elicits specific information. The nurse
sion) and at the same time make important observations establishes the purpose of the interview and controls the
(e.g., note a change in respiratory status or skin color). The interview, at least at the outset. The client responds to
beginning student must learn to make observations and questions but may have limited opportunity to ask ques-
complete tasks simultaneously. tions or discuss concerns. Nurses frequently use directive
interviews to gather and to give information when time is
limited (e.g., in an emergency situation).
Using the Senses By contrast, during a nondirective interview, or rap-
TABLE 10.5 to Observe Client Data port-building interview, the nurse allows the client to con-
Sense Example of Client Data trol the purpose, subject matter, and pacing. Rapport is an
Vision Overall appearance (e.g., body size, general
understanding between two or more people.
weight, posture, grooming); signs of distress A combination of directive and nondirective
or discomfort; facial and body gestures; skin approaches is usually appropriate during the information-
color and lesions; abnormalities of movement; gathering interview. The nurse begins by determining areas
nonverbal demeanor (e.g., signs of anger or of concern for the client. If, for example, a client expresses
anxiety); religious or cultural artifacts (e.g.,
books, icons, candles, beads)
worry about surgery, the nurse pauses to explore the cli-
ent’s worry and to provide support. Simply noting the
Smell Body or breath odors
worry, without dealing with it, can leave the impression
Hearing Lung and heart sounds; bowel sounds; ability that the nurse does not care about the client’s concerns or
to communicate; language spoken; ability to
initiate conversation; ability to respond when
dismisses them as unimportant.
spoken to; orientation to time, person, and
place; thoughts and feelings about self, others, TYPES OF INTERVIEW QUESTIONS
and health status Questions are often classified as closed or open ended,
Touch Skin temperature and moisture; muscle and neutral or leading. Closed questions, used in the
strength (e.g., hand grip); pulse rate, rhythm, directive interview, are restrictive and generally require
and volume; palpable lesions (e.g., lumps, only “yes” or “no” or short factual answers that provide
masses, nodules) specific information. Closed questions often begin with

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 Chapter 10 • Assessing 201

“when,” “where,” “who,” “what,” “do (did, does),” or for advantages and disadvantages of open-ended and
“is (are, was).” Examples of closed questions are “What closed questions.
medication did you take?” “Are you having pain now? A neutral question is a question the client can answer
Show me where it is.” “How old are you?” “When did you without direction or pressure from the nurse, is open
fall?” Closed questions are often used when information ended, and is used in nondirective interviews. Examples
is needed quickly, such as in an emergency situation. Indi- are “How do you feel about that?” “What do you think led
viduals who are highly stressed or have difficulty commu- to the operation?” A leading question, by contrast, is usu-
nicating will find closed questions easier to answer than ally closed, used in a directive interview, and thus directs
open-ended questions. the client’s answer. Examples are “You’re stressed about
Open-ended questions, associated with the nondi- surgery tomorrow, aren’t you?” “You will take your medi-
rective interview, invite clients to discover and explore, cine, won’t you?” The leading question gives the client
elaborate, clarify, or illustrate their thoughts or feelings. less opportunity to decide whether the answer is true or
An open-ended question specifies only the broad topic to not. Leading questions create problems if the client, in an
be discussed and invites answers longer than one or two effort to please the nurse, gives inaccurate responses. This
words. Such questions give clients the freedom to divulge can result in inaccurate data.
only the information that they are ready to disclose. The Try to avoid asking “why” questions. These ques-
open-ended question is useful at the beginning of an inter- tions can be perceived as a form of interrogation by the
view or to change topics and to elicit attitudes. client (Kneisl & Trigoboff, 2013). Because the goal of
Open-ended questions may begin with “what” or questioning is to elicit as much purposeful information
“how.” Examples of open-ended questions are “How have as possible, anything that puts the client on the defensive
you been feeling lately?” “What brought you to the hos- will interfere with reaching that goal. However, in an
pital?” “How did you feel in that situation?” “Would you emergency situation the use of probing and direct ques-
describe more about how you relate to your child?” “What tioning may be appropriate to gain a greater volume
would you like to talk about today?” of data in a shorter period of time (Kneisl & Trigoboff,
The type of question a nurse chooses depends on the 2013).
needs of the client at the time. Nurses often find it necessary
to use a combination of closed and open-ended questions PLANNING THE INTERVIEW AND SETTING
throughout an interview to accomplish the goals of the Before beginning an interview, the nurse reviews avail-
interview and obtain needed information. See Table 10.6 able information, for example, the operative report,

TABLE 10.6 Selected Advantages and Disadvantages of Open-Ended and Closed Questions
OPEN-ENDED QUESTIONS
Advantages Disadvantages
1. They let the interviewee do the talking. 1. They take more time.
2. The interviewer is able to listen and observe. 2. Only brief answers may be given.
3. They reveal what the interviewee thinks is important. 3. Valuable information may be withheld.
4. They may reveal the interviewee’s lack of information, mis- 4. They often elicit more information than necessary.
understanding of words, frame of reference, prejudices, or 5. Responses are difficult to document and require skill in
stereotypes. recording.
5. They can provide information the interviewer may not ask for. 6. The interviewer requires skill in controlling an open-ended
6. They can reveal the interviewee’s degree of feeling about an interview.
issue. 7. Responses require insight and sensitivity from the interviewer.
7. They can convey interest and trust because of the freedom they
provide.
CLOSED QUESTIONS
Advantages Disadvantages
1. Questions and answers can be controlled more effectively. 1. They may provide too little information and require follow-up
2. They require less effort from the interviewee. questions.
3. They may be less threatening, since they do not require expla- 2. They may not reveal how the interviewee feels.
nations or justifications. 3. They do not allow the interviewee to volunteer possibly valuable
4. They take less time. information.
5. Information can be asked for sooner than it would be 4. They may inhibit communication and convey lack of interest by
volunteered. the interviewer.
6. Responses are easily documented. 5. The interviewer may dominate the interview with questions.
7. Questions are easy to use and can be handled by unskilled
interviewers.

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information about the current illness, or literature about

QSEN Patient-Centered Care: Personal Space
the client’s health problem. The nurse also reviews the
agency’s data collection form to identify which data must The accepted distance between individuals in a conver-
be collected and which data are within the nurse’s discre- sation varies. Some individuals are comfortable with
tion to collect based on the specific client. If a form is not less distance than others. Anxiety and direct eye contact
available, most nurses prepare an interview guide to help increase the need for space. Physical contact is used only
them remember areas of information and determine what if it has a therapeutic purpose. It is important to note that
questions to ask. The guide includes a list of topics and touch, even a simple hand on the shoulder, can be misin-
subtopics rather than a series of questions. terpreted, especially between individuals of the opposite
Both nurses and clients are made comfortable in order gender.
to encourage an effective interview by balancing several
factors. Each interview is influenced by time, place, seat- Language Failure to communicate in language the cli-
ing arrangement or distance, and language. ent can understand is a form of discrimination. The nurse
Time Nurses need to plan interviews with clients when must convert complicated medical terminology into com-
the client is physically comfortable and free of pain, and mon English usage, and interpreters or translators are
when interruptions by friends, family, and other health needed if the client and the nurse do not speak the same
professionals are minimal. Nurses should schedule inter- language or dialect (a variation in a language spoken in a
views with clients in their homes at a time selected by particular geographic region). Translating medical termi-
the client. nology is a specialized skill because not everyone who is
fluent in the conversational form of a language is familiar
Place A well-lit, well-ventilated room that is relatively
with anatomic or other health terms. Interpreters, how-
free of noise, movements, and distractions encourages
ever, may make judgments about precise wording but
communication. In addition, a place where others cannot
also about subtle meanings that require additional expla-
overhear or see the client is desirable.
nation or clarification according to the specific language
Seating Arrangement By standing and looking down at a and ethnicity. They may edit the original source to make
client who is in bed or in a chair, the nurse risks intimidat- the meaning clearer or more culturally appropriate.
ing the client. When a client is in bed, the nurse can sit at If giving written documents to clients, the nurse must
a 45-degree angle to the bed. This position is less formal determine that the client can read in his or her native lan-
than sitting behind a table or standing at the foot of the guage. Live translation is preferred since the client can then
bed. During an initial admission interview, a client may ask questions for clarification. Nurses must be cautious
feel less confronted if there is an overbed table between when asking family members, client visitors, or agency
the client and the nurse. Sitting on a client’s bed hems the nonprofessional staff to assist with translation. Issues of
client in and makes staring difficult to avoid. confidentiality or gender mismatch can interfere with
A seating arrangement with the nurse behind a desk effective communication. Services such as AT&T Language
and the client seated across creates a formal setting that Line are available 24 hours a day in about 170 languages,
suggests a business meeting between a superior and a sub- for a fee paid by the healthcare provider. Many large agen-
ordinate. In contrast, a seating arrangement in which the cies possess their own on-call translator services for the
parties sit on two chairs placed at right angles to a desk languages or dialects commonly spoken in their area.
or table or a few feet apart, with no table between, creates Even among clients who speak English, there may be
a less formal atmosphere, and the nurse and client tend differences in understanding terminology. Clients from
to feel on equal terms. In groups, a horseshoe or circular different parts of the country may have strong accents,
chair arrangement can avoid a superior or head-of-the- or clients less well educated and teen clients may ascribe
table position. different meanings to words. For example, “cool” may
Distance The distance between the interviewer and inter- imply something good to one client and something not
viewee should be neither too small nor too great, because warm to another. The nurse must always confirm accurate
people feel uncomfortable when talking to someone who understandings.
is too close or too far away. Proxemics is the study of use
of space. As a species, humans are highly territorial but STAGES OF AN INTERVIEW
we are rarely aware of it unless our space is somehow
An interview has three major stages: the opening or intro-
violated. Most people feel comfortable maintaining a
duction, the body or development, and the closing.
distance of 2 to 3 feet during an interview. Some clients
require more or less personal space, depending on their The Opening The opening can be the most important
cultural and personal needs. For additional information, part of the interview because what is said and done at
see Chapter 21 . that time sets the tone for the remainder of the interview.

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 Chapter 10 • Assessing 203

The purposes of the opening are to establish rapport and Client: OK. That’s all right with me.
orient the interviewee. Nurse: If there is anything you don’t want to talk
Establishing rapport is a process of creating goodwill about, please feel free to say so. Everything you tell
and trust. It can begin with a greeting (“Good morning, me will be confidential and shared only with others
Mr. Johnson”) or a self-introduction (“Good morning. I’m who have the legal right to know it.
Becky James, a nursing student”) accompanied by nonver- Client: Sure, that will be fine.
bal gestures such as a smile, a handshake, and a friendly
The Body In the body of the interview, the client com-
manner. The nurse must be careful not to overdo this
municates what he or she thinks, feels, knows, and per-
stage; too much superficial talk can arouse anxiety about
ceives in response to questions from the nurse. Effective
what is to follow and may appear insincere.
development of the interview demands that the nurse use
In orientation, the nurse explains the purpose and nature
communication techniques that make both parties feel
of the interview, for example, what information is needed,
comfortable and serve the purpose of the interview (see
how long it will take, and what is expected of the client. The
Chapter 16 ). For communicating during an interview,
nurse tells the client how the information will be used and
see the Practice Guidelines.
usually states that the client has the right not to provide data.
The following is an example of an interview introduction: The Closing The nurse terminates the interview when
Step 1. Establish Rapport the needed information has been obtained. In some cases,
however, a client terminates it, for example, when decid-
Nurse: Hello, Ms. Goodwin, I’m Ms. Fellows. I’m a ing not to give any more information or when unable to
nursing student, and I’ll be assisting with your care offer more information for some other reason—fatigue,
here today. for example. The closing is important for maintaining
Client: Hi. Are you a student from the college? rapport and trust and for facilitating future interactions.
Nurse: Yes, I’m in my final year. Are you familiar with The following techniques are commonly used to close an
the campus? interview:
Client: Oh, yes! I’m an avid football fan. My nephew
graduated in 2017, and I often attend football games 1. Offer to answer questions: “Do you have any ques-
with him. tions?” “I would be glad to answer any questions
Nurse: That’s great! Sounds like fun. you have.” Be sure to allow time for the individual
Client: Yes, I enjoy it very much. to answer, or the offer will be regarded as insincere.
2. Conclude by saying, “Well, that’s all I need to know
Step 2. Orientation
for now” or “Well, those are all the questions I have
Nurse: May I sit down with you here for about ten for now.” Preceding a remark with the word “well”
minutes to talk about your care while you’re here? generally signals that the end of the interaction is
Client: All right. What do you want to know? near.
Nurse: Well, to plan your care after your operation, I’d 3. Thank the client: “Thank you for your time and help.
like to get some information about your usual daily The questions you have answered will be helpful in
activities and what you expect here in the hospital. I’ll planning your nursing care.” You may also shake the
take notes while we talk to get the important points client’s hand.
and have them available to the other staff who will 4. Express concern for the client’s welfare and future:
also look after you. “I hope all goes well for you.”

PRACTICE GUIDELINES Communication During an Interview

• Listen attentively, using all your senses, and speak slowly and • Avoid using personal examples, such as saying, “If I were
clearly. you. . . .”
• Use language the client understands, and clarify points that are • Nonverbally convey respect, concern, interest, and acceptance.
not understood. • Be aware of the client’s and your own body language.
• Plan questions to follow a logical sequence. • Be conscious of the client’s and your own voice inflection, tone,
• Ask only one question at a time. Multiple questions limit the cli- and affect.
ent to one choice and may confuse the client. • Sit down to talk with the client (be at an even level).
• Acknowledge the client’s right to look at things the way they • Use and accept silence to help the client search for more
appear to him or her and not the way they appear to the nurse thoughts or to organize them.
or someone else. • Use eye contact and be calm, unhurried, and sympathetic.
• Do not impose your own values on the client.

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 204 Unit 3 • The Nursing Process

5. Plan for the next meeting, if there is to be one, or state abdomen, and extremities; and ends at the toes. The nurse
what will happen next. Include the day, time, place, using a body systems approach investigates each system
topic, and purpose: “Let’s get together again here on individually, that is, the respiratory system, the circula-
the fifteenth at nine a.m. to see how you are man- tory system, the nervous system, and so on. During the
aging.” Or “Ms. Goodwin, I will be responsible for physical examination, the nurse assesses all body parts
giving you care three mornings per week while you and compares findings on each side of the body (e.g.,
are here. I will be here each Monday, Tuesday, and lungs). These techniques are discussed in detail in Chap-
Wednesday between eight o’clock and noon. At those ters 28 and 29 .
times, we can adjust your care as needed.” Instead of giving a complete examination, the nurse
6. Provide a summary to verify accuracy and agree- may focus on a specific problem area noted from the nurs-
ment. Summarizing serves several purposes: It helps ing assessment, such as the inability to urinate. On occa-
to terminate the interview, it reassures the client that sion, the nurse may find it necessary to resolve a client
the nurse has listened, it checks the accuracy of the complaint or problem (e.g., shortness of breath) before
nurse’s perceptions, it clears the way for new ideas, completing the examination. Alternatively, the nurse may
and it helps the client to note progress and a forward perform a screening examination. A screening examina-
direction. “Let’s review what we have just covered tion, also called a review of systems, is a brief review of
in this interview.” Summaries are particularly help- essential functioning of various body parts or systems.
ful for clients who are anxious or who have difficulty An example of a screening examination is the nursing
staying with the topic. “Well, it seems to me that you admission assessment form shown in Figure 10.5. Data
are especially worried about your hospitalization and obtained from this examination are measured against
chest pain because your father died of a heart attack norms or standards, such as ideal height and weight stan-
five years ago. Is that correct? I’ll discuss this with you dards or norms for body temperature or blood pressure
again tomorrow, and we’ll decide what plans need to levels.
be made to help you.”

Examining Organizing Data

The physical examination or physical assessment is a sys- The nurse uses a written (or electronic) format that orga-
tematic data collection method that uses observation (i.e., nizes the assessment data systematically. This is often
the senses of sight, hearing, smell, and touch) to detect referred to as a nursing health history, nursing assess-
health problems. To conduct the examination, the nurse ment, or nursing database form. The format may be
uses techniques of inspection, auscultation, palpation, and modified according to the client’s physical status such
percussion (see Chapter 29 ). as one focused on musculoskeletal data for orthopedic
The physical examination is carried out systemati- clients.
cally. It may be organized according to the examiner’s
preference, in a head-to-toe approach or a body systems
approach. Usually, the nurse first records a general impres- Conceptual Models and Frameworks
sion about the client’s overall appearance and health sta- Most schools of nursing and health care agencies have
tus: for example, age, body size, mental and nutritional developed their own structured assessment format. Many
status, speech, and behavior. Then the nurse takes such of these are based on selected nursing models or frame-
measurements as vital signs, height, and weight. The works (see Chapter 1 ). Three examples are Gordon’s
cephalocaudal or head-to-toe approach begins the functional health pattern framework, Orem’s self-care
examination at the head; progresses to the neck, thorax, model, and Roy’s adaptation model.

LIFESPAN CONSIDERATIONS Assessment

CHILDREN • The parents become the major source of subjective data,
Consider this example: A 4-year-old girl is admitted following emer- although the child should be encouraged to tell the nurse how
gency surgery for a ruptured appendix. She is awake and alert, but she is feeling.
refuses to talk. Her parents have had little sleep for more than 24 • Objective data collected include vital signs including level of
hours and are extremely anxious. and response to pain; bleeding or discharge from the incision;
mobility; integrity of dressings, IV lines, catheters, nasogastric
• Gathering assessment data in this situation requires the nurse
tubes or other medical devices; and mental status.
to be sensitive to the parents’ needs for sleep and assurance.
• Since children are a part of families, assessment will include
At the same time, the nurse must collect information to com-
observation of family dynamics and questions that could lead to
pile an adequate database for appropriate nursing care deci-
care of the family system.
sions. Assessment will involve monitoring the condition of the
child as she recovers from surgery and being alert to potential
problems.

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 Chapter 10 • Assessing 205

Gordon (2016) provides a framework of 11 func-

BOX 10.2 Roy’s Adaptation Model
tional health patterns. The 11 functional health patterns
are health perception and management, nutritional- ADAPTIVE MODES
metabolic, elimination, activity, sleep, cognitive, self- 1. Physiologic needs
perception and self-concept, role relationship, sexuality, • Activity and rest
• Nutrition
coping and stress, and value belief systems. Gordon
• Elimination
uses the word pattern to signify a sequence of recurring • Fluid and electrolytes
behavior. The nurse collects data about dysfunctional • Oxygenation
as well as functional behavior. Thus, by using Gordon’s • Protection
framework to organize data, nurses are able to discern • Regulation: temperature
• Regulation: the senses
emerging patterns.
• Regulation: endocrine system
Orem’s self-care model (2001) delineates eight univer-
2. Self-concept
sal self-care requisites of humans. The model describes • Physical self
the client’s need for adequate nutrition, normal elimina- • Personal self
tion, and adequate rest to promote normal human func- 3. Role function
tioning and development. Roy (2009) outlines the data to 4. Interdependence
be collected according to the Roy adaptation model and The Roy Adaptation Model by Sister Callista Roy. Copyright © 2009 by Prentice-Hall.

classifies observable behavior into four categories: physi-

ologic, self-concept, role function, and interdependence
(Box 10.2).
Figure 10.5 ■ is a concise data collection tool that is the box differ somewhat from those in Figure 10.5. As a
organized according to body systems and specific nursing rule, the nurse organizes the data using the same model
concerns (e.g., screening for falls and allergies); it does not on which the data collection tool is based. However, differ-
use one particular nursing model. In Box 10.3, the data for ent models are provided here to demonstrate differences
the case study client Margaret O’Brien from Figure 10.5 in organizing frameworks, and to show that the nurse is
are shown after being organized according to Gordon’s not limited to the exact framework provided by the data
11 functional health patterns. Note how the categories in collection tool.

Figure 10.5 ■ Assessment for Margaret O’Brien.

iCare.

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 206 Unit 3 • The Nursing Process

Figure 10.5 ■ Continued

• Nutritional assessment
Wellness Models • Life-stress analysis
Nurses use wellness models to assist clients to identify • Lifestyle and health habits
health risks and to explore lifestyle habits and health • Health beliefs
behaviors, beliefs, values, and attitudes that influence • Sexual health
levels of wellness. Such models generally include the • Spiritual health
following: • Relationships
• Health risk appraisal.
• Health history
• Physical fitness evaluation See Chapter 20 for details.

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 Chapter 10 • Assessing 207

BOX 10.3 Data for Margaret O’Brien, Organized According to Functional Health Patterns
HEALTH PERCEPTION AND HEALTH MANAGEMENT • Children are with their grandparents until husband returns
• Aware/understands medical diagnosis • States “good” relationships with friends and coworkers
• Gives thorough history of illnesses and surgeries • Nursing student and part-time home health aid
• Complies with Synthroid regimen
• Relates progression of illness in detail SELF-PERCEPTION OR SELF-CONCEPT
• Expects to have antibiotic therapy and “go home in a day or two” • Expresses “concern” and “worry” over leaving her children with
• States usual eating pattern “three meals a day” their grandparents until husband returns
• Anxiety related to missing her nursing classes, missing her
NUTRITIONAL-METABOLIC medical–surgical clinical day, and inability to study
• 158 cm (5 ft, 2 in.) tall; weighs 56 kg (125 lb) • Well-groomed; says, “Too tired to put on makeup”
• Usual eating pattern “three meals a day”
• “No appetite” since having “cold” COPING-STRESS
• Has not eaten today; last fluids at noon • Anxious: “I can’t breathe”
• Nauseated • Facial muscles tense; trembling
• Oral temperature 39.4°C (103°F) • Expresses concerns about work: “I’ll never get caught up”
• Decreased skin turgor
VALUE-BELIEF
ELIMINATION • Catholic
• Usually no problem • No special practices desired except anointing of the sick
• Decreased urinary frequency and amount * 2 days • Middle-class, professional orientation
• Last bowel movement yesterday, formed, states was “normal” • No wish to see chaplain or priest at present

ACTIVITY-EXERCISE MEDICATION AND HISTORY

• No musculoskeletal impairment • Synthroid 0.1 mg per day
• Difficulty sleeping because of cough • Client has history of appendectomy, partial thyroidectomy
• “Can’t breathe lying down”
• States “I feel weak” NURSING PHYSICAL ASSESSMENT
• Short of breath on exertion • 33 years old
• Exercises daily • Height 158 cm (5 ft, 2 in.); weight 56 kg (125 lb)
• TPR 39.4°C (103°F), 92 beats/min, 28/min
COGNITIVE-PERCEPTUAL • Radial pulses weak, regular
• No sensory deficits • Blood pressure 122/80 mmHg sitting
• Pupils 3 mm, equal, brisk reaction • Skin hot and pale, cheeks flushed
• Oriented to time, place, and person • Mucous membranes dry and pale
• Responsive, but fatigued • Respirations shallow; chest expansion less than 3 cm
• Responds appropriately to verbal and physical stimuli • Cough productive of small amounts of pale pink sputum
• Recent and remote memory intact • Inspiratory crackles auscultated throughout right upper and
• States “short of breath” on exertion lower chest
• Reports “pain in lungs,” especially when coughing • Diminished breath sounds on right side
• Experiencing chills • Abdomen soft, not distended
• Reports nausea • Old surgical scars: anterior neck, RLQ abdomen
• Diaphoretic
ROLES-RELATIONSHIPS
• Lives with husband, 13-year-old daughter, and 5-year-old son
• Husband out of town; will be back tomorrow afternoon

Nonnursing Models •
•
Nervous system
Musculoskeletal system
Frameworks and models from other disciplines may • Gastrointestinal system
also be helpful for organizing data. These frameworks • Genitourinary system
are narrower than the model required in nursing; there- • Reproductive system
fore, the nurse usually needs to combine these with other • Immune system.
approaches to obtain a complete history.

Body Systems Model Maslow’s Hierarchy of Needs

The body systems model focuses on abnormalities of the Maslow’s hierarchy of needs clusters data pertaining to
following anatomic systems: the following:
• Integumentary system • Physiologic needs (survival needs)
• Respiratory system • Safety and security needs
• Cardiovascular system • Love and belonging needs

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 208 Unit 3 • The Nursing Process

• Self-esteem needs • Differentiate between cues and inferences. Cues are sub-
• Self-actualization needs. jective or objective data that can be directly observed by
the nurse; that is, what the client says or what the nurse
See Chapter 19 for details.
can see, hear, feel, smell, or measure. Inferences are the
Developmental Theories nurse’s interpretation or conclusions made based on
Several physical, psychosocial, cognitive, and moral the cues (e.g., a nurse observes the cues that an incision
developmental theories may be used by the nurse in spe- is red, hot, and swollen; the nurse makes the inference
cific situations. Examples include the following: that the incision is infected).
• Avoid jumping to conclusions and focusing in the
• Havighurst’s age periods and developmental tasks wrong direction to identify problems.
• Freud’s five stages of development
• Erikson’s eight stages of development Not all data require validation. For example, data such
• Piaget’s phases of cognitive development as height, weight, birth date, and most laboratory stud-
• Kohlberg’s stages of moral development. ies that can be measured with an accurate scale can be
accepted as factual. As a rule, the nurse validates data
See Chapter 23 for additional information. when there are discrepancies between data obtained in
the nursing interview (subjective data) and the physical
examination (objective data), or when the client’s state-
Validating Data ments vary at different times in the assessment. Guide-
lines for validating data are shown in Table 10.7.
The information gathered during the assessment phase
To collect data accurately, nurses need to be aware
must be complete, factual, and accurate because the nurs-
of their own biases, values, and beliefs and to separate
ing diagnoses and interventions are based on this informa-
fact from inference, interpretation, and assumption (see
tion. Validation is the act of “double-checking” or verifying
Chapter 9 ). For example, a nurse seeing a man holding
data to confirm that it is accurate and factual. Validating
his arm to his chest might assume that he is experiencing
data helps the nurse complete these tasks:
chest pain, when in fact it is his hand that hurts.
• Ensure that assessment information is complete. To build an accurate database, nurses must validate
• Ensure that objective and related subjective data assumptions regarding the client’s physical or emotional
agree. behavior. In the previous example, the nurse should ask
• Obtain additional information that may have been the client why he is holding his arm to his chest. The
overlooked. client’s response may validate the nurse’s assumptions

TABLE 10.7 Validating Assessment Data

Guidelines Example
Compare subjective and objective data to verify the client’s state- Client’s perceptions of “feeling hot” need to be compared with
ments with your observations. ­measurement of the body temperature.
Clarify any ambiguous or vague statements. Client: “I’ve felt sick on and off for 6 weeks.”
Nurse: “Describe what your sickness is like. Tell me what you mean
by ‘on and off.’”
Be sure your data consist of cues and not inferences. Observation: Dry skin and reduced tissue turgor
Inference: Dehydration
Action: Collect additional data that are needed to make the
­inference in the diagnosing phase. For example, determine the
client’s fluid intake, amount and appearance of urine, and blood
pressure.
Double-check data that are extremely abnormal. Observation: A resting pulse of 30 beats/min or a blood pressure of
210/95 mmHg
Action: Repeat the measurement. Use another piece of equipment
as needed to confirm abnormalities, or ask someone else to collect
the same data.
Determine the presence of factors that may interfere with accurate A crying infant will have an abnormal respiratory rate and will need
measurement. quieting before accurate assessment can be made.
Use references (textbooks, journals, research reports) to explain A nurse considers tiny purple or bluish-black swollen areas under
phenomena. the tongue of an older adult client to be abnormal until reading
about physical changes of aging. Such varicosities are common.

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 Chapter 10 • Assessing 209

or prompt further questioning. Figure 10.5 indicates that health status. Data are recorded in a factual manner
the nurse auscultated Margaret O’Brien’s heart and lungs and not interpreted by the nurse. For example, the nurse
to validate her statement that she had “lung pain” and records the client’s breakfast intake (objective data) as
“shortness of breath” on exertion. Failure to v ­ alidate “coffee 240 mL, juice 120 mL, 1 egg, and 1 slice of toast,”
assumptions can lead to an inaccurate or incomplete rather than as “­appetite good” (a judgment). A judg-
nursing assessment and could compromise client safety. ment or conclusion such as “appetite good” or “normal
­a ppetite” may have different meanings for ­d ifferent

Documenting Data ­people. To increase ­accuracy, the nurse records subjec-

tive data in the ­c lient’s own words, using quotation
To complete the assessment phase, the nurse records marks. ­R estating in other words what someone says
­c lient data. Accurate documentation is essential and increases the chance of changing the original mean-
should include all data collected about the client’s ing (see Chapter 14 ).

Critical Thinking Checkpoint

Eighty-two-year-old Ms. T. is in the hospital for hip replacement surgery. 3. What exactly would you say to her to determine if someone will
1. What are the key areas of information to obtain regarding her be at home to assist her after discharge?
past history? 4. Which other sources of data might be appropriate to access in
2. Which physiologic systems are the most important for data col- her case?
lection before her surgery? Answers to Critical Thinking Checkpoint questions are available on the faculty resources site. Please
consult with your instructor.

Chapter 10 Review
CHAPTER HIGHLIGHTS
• The nursing process is a systematic, rational method of planning • Planning involves setting priorities, formulating goals or desired out-
and providing individualized nursing care for individuals, families, comes, and selecting nursing interventions.
communities, and groups. • Implementing is carrying out the nursing interventions. It includes
• The goals of the nursing process are to identify a client’s health reassessing the client, determining the nurse’s need for assis-
status and actual or potential healthcare needs, to establish plans tance, supervising delegated care, and documenting nursing
to meet the identified needs, and to deliver and evaluate specific activities.
nursing interventions to meet those needs. • Evaluating is the process of comparing data to outcomes to deter-
• The nursing process is organized into five interrelated, interdepen- mine the status of the problem. It includes review and modification
dent phases: assessing, diagnosing, planning, implementing, and of the care plan.
evaluating. • Assessment involves active participation by the client and nurse
• The nursing process can be used in all healthcare settings. It is in obtaining subjective and objective data about the client’s health
cyclic and dynamic, client centered, focused on problem-solving status.
and decision-making, interpersonal and collaborative, and univer- • Subjective data are the client’s personal perceptions, often gath-
sally applicable, and requires critical thinking and clinical reasoning. ered during the nursing health history.
• Clinical reasoning allows the nurse to reflect on the care delivered • Objective data (e.g., data observed and collected during the physi-
throughout the phases of the nursing process. cal examination) are detectable by an observer.
• Assessing involves collecting, organizing, validating, and docu- • The client is the primary source of data. Secondary sources are
menting data. family members and other support persons, other health profes-
• Diagnosing is analyzing data, identifying a client’s potential or actual sionals, records and reports, laboratory and diagnostic analyses,
health problems, and formulating diagnostic statements. and relevant literature.

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 210 Unit 3 • The Nursing Process

• The primary methods of data collection are observing, interviewing, • Nursing models provide formats for collecting and organizing cli-
and examining. ent data.
• Observation is a conscious, deliberate skill involving use of the • The nursing assessment must be complete and accurate because
senses. nursing diagnoses and interventions are based on this information.
• The nurse uses a combination of directive and nondirective inter- • Some data must be validated. Subjective data can be used to vali-
viewing (including closed and open-ended questions) to obtain the date objective data, and vice versa.
nursing health history.

TEST YOUR KNOWLEDGE

1. When learning how to implement the nursing process into a plan 7. In the validating activity of the assessing phase of the nursing
of care for a client, the student nurse realizes that part of the process, the nurse performs which of the following?
purpose of the nursing process is to do which of the following? 1. Collects subjective data.
1. Deliver care to a client in an organized way 2. Applies a framework to the collected data.
2. Implement a plan that is close to the medical model 3. Confirms data are complete and accurate.
3. Identify client needs and deliver care to meet those needs 4. Records data in the client record.
4. Make sure that standardized care is available to clients 8. A major characteristic of the nursing process is which of the
2. A nursing student is learning how to implement the nursing following?
­process in the clinical area. Which of the following does the 1. A focus on client needs
­purpose of the diagnosis phase include? 2. Its static nature
1. Develop a list of problems 3. An emphasis on physiology and illness
2. Identify client strengths 4. Its exclusive use by and with nurses
3. Develop a plan 9. Which statement would be true regarding use of the observing
4. Specify goals and outcomes method of data collection?
5. Identify problems that can be prevented 1. When observing, the nurse uses only the visual sense.
3. Which element is best categorized as secondary subjective 2. Observing is done only when no other nursing interventions
data? are being performed at the same time.
1. The nurse measures a weight loss of 10 pounds since the 3. Data should be gathered as they occur, rather than in any
last clinic visit. particular order.
2. Spouse states the client has lost all appetite. 4. Observed data should be interpreted in relation to other
3. The nurse palpates edema in lower extremities. sources of collected data.
4. Client states severe pain when walking up stairs. 10. Which of the following represent effective planning of the inter-
4. During an initial interview, the client makes this statement: view setting? Select all that apply.
“I don’t understand why I have to have surgery, I’m really 1. Keep the lighting dimmed so as not to stress the client’s
not that sick or in pain right now.” What is the nurse’s best eyes.
response? 2. Ensure that no one can overhear the interview
1. “It’s OK to be worried. Surgery is a big step.” conversation.
2. “What kind of questions do you have about your surgery?” 3. Stand near the client’s head while he or she is in the bed or
3. “I think these are things you should be asking your doctor.” chair.
4. “Have you had surgery before?” 4. Keep approximately 3 feet from the client during the
5. The use of a conceptual or theoretical framework for collect- interview.
ing and organizing assessment data ensures which of the 5. Use a standard form to be sure all relevant data are covered
following? in the interview.
1. Correlation of the data with other members of the healthcare See Answers to Test Your Knowledge in Appendix A.
team
2. Demonstration of cost-effective care
3. Utilization of creativity and intuition in creating a plan
of care
4. Collection of all necessary information for a thorough
appraisal
6. Which of the following is the purpose of assessing?
1. Establish a database of client responses to his or her health
status.
2. Identify client strengths and problems.
3. Develop an individualized plan of care.
4. Implement care, prevent illness, and promote wellness.

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 Chapter 10 • Assessing 211

READINGS AND REFERENCES

Suggested Reading References Orlando, I. (1961). The dynamic nurse–patient relationship.
Aria, A., Sander, R., & Siek, T. (2018). Simulations as an American Nurses Association. (2015). Nursing: Scope and New York, NY: Putnam.
assessment strategy to assist with unit placement standards of nursing practice (3rd ed.). Silver Spring, MD: Roy, C. (2009). The Roy adaptation model (3rd ed.). Upper
for new graduate nurses. Journal for Nurses in Pro- Author. Saddle River, NJ: Prentice Hall.
fessional Development, 34(2), 78–83. doi:10.1097/ D’Amico, D., & Barbarito, C. (2016). Health & physical assess- Wiedenbach, E. (1963). The helping art of nursing. American
NND.0000000000000424 ment in nursing (3rd ed.). Upper Saddle River, NJ: Pearson Journal of Nursing, 63(11), 54–57. doi:10.2307/3453018
The nurse residency program in the healthcare facility Prentice Hall. Wilkinson, J. M. (2012). Nursing process and critical thinking
where this study was conducted revised the onboard- Feo, R., Rasmussen, P., Wiechula, R., Conroy, T., & Kitson, A. (5th ed.). Upper Saddle River, NJ: Pearson.
ing of new graduate nurses with the use of simulation (2017). Developing effective and caring nurse-patient rela-
and lecture, along with critical thinking case studies and tionships. Nursing Standard, 31(28), 54–62. doi:107748/ Selected Bibliography
active learning experiences. The education team utilized ns.2017.e10735 Alfaro-LeFevre, R. (2017). Critical thinking, clinical reasoning,
simulation and a simulation assessment score for forma- Gordon, M. (2016). Manual of nursing diagnosis (13th ed.). and clinical judgment: A practical approach (6th ed.). Phila-
tive and summative evaluation. The addition of simulation Boston, MA: Jones & Bartlett. delphia, PA: Elsevier.
resulted in increased readiness for nursing practice and Hall, L. (1955, June). Quality of nursing care. Public Health Frank, C. A., Schroeter, K., & Shaw, C. (2017). Addressing
increased safety. News. Newark, NJ: State Department of Health. traumatic stress in the acute traumatically injured patient.
Johnson, D. E. (1959). A philosophy of nursing. Nursing Out- Journal of Trauma Nursing, 24(2), 78–84. doi:10.1097/
Related Research look, 7, 198–200. JTN.0000000000000270
Colla, L., Fuller-Tyszkiewicz, M., Tomyn, A., Richardson, B., The Joint Commission. (2019). Documentation assistance The Joint Commission. (2019). Nursing assessments—
& Tomyn, J. (2016). Use of weekly assessment data to provided by scribes. Retrieved from https://www.joint- Licensed Practical Nurse. Retrieved from https://www
enhance evaluation of a subjective wellbeing interven- commission.org/standards_information/jcfaqdetails. .jointcommission.org/standards_information/jcfaqdetails.
tion. Quality of Life Research, 25, 517–524. doi:10.1007/ aspx?StandardsFAQId=1809 aspx?StandardsFaqId=1590&ProgramId=46
s11136-015-1150-0 Kneisl, C. R., & Trigoboff, E. (2013). Contemporary psychiat- Vaughn, J., & Parry, A. (2016). Assessment and management
Kohtz, C., Brown, S. C., Williams, R., & O’Connor, P. A. (2017). ric–mental health nursing (3rd ed.). Upper Saddle River, NJ: of the septic patient: Part 2. British Journal of Nursing,
Physical assessment techniques in nursing education: Prentice Hall. 25(21), 1196–1200. doi:10.12968/bjon.2016.25.21.1196
A replicated study. Journal of Nursing Education, 56(5), Orem, D. E. (2001). Nursing: Concepts of practice (6th ed.).
287–291. doi:10.3928/01484834-20170421-06 St. Louis, MO: Mosby.

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