JOSCO COLLEGE OF NURSING EDAPPONE PANDALAM

SEMINAR ON HEALTH ILLNESS PROBLEMS HEALTH

BEHAVIOURS AND METHODS OF DATA COLLECTION

SUBMITTED TO:

SUBMITTED BY:

MRS:RINCY

MRS:RAKHI R NAIR

LECTURER

1 ST YEAR MSC NURSING

JOSCO COLLEGE OF NURSING

EDAPPON

JOSCO COLLEGE OF NURSING

EDAPPON

SUBMITTED ON : 13.11.13

INTRODUCTION
A nurse follows nursing process to organize and follow nursing care. Use of the process
allows the nurse to integrate elements of critical thinking to make judgments and to take
actions based on reason. The nursing process is used to identify diagnose and treat
human responses to health and illness. The process includes five steps. Assessment,
nursing diagnosis, planning implementation and evaluation
Assessing is the systematic and continuous collection validation and
communication of patient data. These data reflex how health functioning is enhanced by
health promotion or compromised by illness or injury
DEFINITION
HEALTH
Health is a state of complete physical mental and social wellbeing and not merely an
absence of disease or infirmity
ILLNESS
It is a state in which a persons physical emotional intellectual social developmental or
spiritual functioning is diminished or impaired compared with previous experience
ASSESSMENT
It is the deliberate and systematic collection of data to determine clients current and
past health status and to determine the current and past coping patterns
Every health care professional perform performs assessment to make professional
judgments related to his or her client. However the purpose of nursing history and
physical examination differs greatly from that of medical or other type of examinations
ELEMENTS OF ASSESMENT

Data
Data
Data
Data
Data

collection
validation
interpretation
clustering
documentation

PURPOSE OF NURSING ASSESSMENT

To establish a data base concerning a clients physical psychological and
emotional health inorder to identify health promoting behaviors as well as actual and or
potential health problems
Nursing health history
Physical assessment
Result of diagnostic and laboratory test
Material from other health personnel

TYPES OF ASSESSMENT
INITIAL COMPREHENSIVE ASSESSMENT
An initial assessment is also called an admission assessment and is performed when the
client enters the health care from a health care agency. The purpose is to evaluate the
clients health status to identify the functional health patterns that are problematic and
to provide an indepth comprehensive data base which is critical for evaluating changes
in the clients health status in subsequent assessments.
PROBLEM FOCUSED ASSESSMENT
A problem focused assessment collects data about health problem that has already
been identified. This type of assessment has a narrower scope and shorter time frame
than the initial assessment. In focus assessments the nurse determines whether the
problems still exist and whether the status of problem has changed. This assessment
also includes the appraisal of any new overlooked or misdiagnosed problems. Intensive
care units may perform focus assessments every few minutes.
EMERGENCY ASSESSMENT
Emergency assessment takes place in life threatening situations in which the
preservation of life is the top priority. Time is of the essence in rapid identification of and
interventions for the clients health problems. Often the clients difficulties involve airway
breathing and circulatory problems. Abrupt changes in self concept or roles or
relationship also can initiate an emergency. Emergency assessment focus on few
essential health patterns and is not comprehensive
TIME LAPSED OR ON GOING ASSESSMENT
Time lapsed reassessment is another type of assessment takes place after the initial
assessment to evaluate any changes in the clients functional health. Nurse perform time
lapsed reassessment when substantial period of time has elapsed between assessment
STEPS OF ASSESSMENT
Collection of data
Validation of data
Organization of data
Recording and documentation of data
COLLECTION OF DATA
Gathering information about the client includes
Physical, psychological, social, emotional, cultural, spiritual factors that
may affect clients health status
Past health history of client
Current and present health problems of the client
TYPES OF DATA
a) SUBJECTIVE DATA -

 also referred to as symptoms or cessations.

Information from the clients point of view is described by persons
experiencing it.
Information supplied by family members , significant others, other health
professionals are considered as subjective data
b) OBJECTIVE DATA
Also referred to as sign
Those that can be detected or measured using accepted standards or norm
Mainly collected by general observation and by using the four physical
examination techniques: inspection , percussion, palpation, auscultation
SOURCES OF DATTA COLLCETION

Primary source - data directly gathered from the client using interview and
physical examination
Secondary source- data gathered from clients family members significant others
clients medical records chart other members of the health team and related care
literature journals

METHODS OF DATA COLLECTION

INTERVIEW
It is a planned purposeful conversation and communication with the client to get
information identify problems evaluate change to teach or to provide support or
counseling. Interview consists of asking questions designed to elicit subjective data from
the client or family members.
PHASES OF INTERVIEW

Preparatory phase
Introduction
Working phase
Termination

PREPARATORY PHASE
Before initiating the interview the nurse prepares to meet the patient by reading current
and past records and reports available. It is important to let know ones stereotypes and
prejudice affects the nurse patient relationship
During this phase the nurse should ensure that the
enviournment in which the interview is to be conducted is private and relaxed. The
interview should be scheduled when both nurse and patient are free of concerns and
distractions so that they are concentrate on the task
INTRODUCTION
The interview introduction is crucial because it sets the tone not only for the remainder
of the interview but also for the every following nurse patient interaction. At the end of
this phase of interview the patient should know the name of the primary nurse and what
he or she can expect of nursing care should sense that the nurse is competent and cares

about him or her and should know what is expected of him or her in terms of developing
the plan of care and participating in its execution.
WORKING PHASE
During the working phase the nurse gathers information about the clients past and
present health status. The nurse should begin the interview with current complaint or
concern and proceed according to the identified format. The nurse should use
communication skill during the interview that include both verbal and non verbal
techniques that facilitate the acquisition of the data base

VERBAL TECHNIQUE
Verbal communication during the interview process requires a conscious effort on the
part of the nurse. During the interview the nurse uses two types of questioning methods.
Open ended and closed ended questions
OPEN ENDED QUESTIONS the nurse uses open ended questions to elicit information
from the client about the feelings concerns opinions and perceptions and to allow for the
validation of both subjective and objective data
CLOSED QUESTIONS They are questions that can be answered briefly or with one word
response
REFLEXION
This is another verbal technique. Reflexion of feelings involves informing the client about
the feelings that the nurse perceives the client is having. This is done to assist the client
in focusing on these feelings and making him or her more aware of them

NON VERBAL TECHNIQUES

A variety of non verbal techniques can hinder or facilitate the communication processes
and its effect on the nurse patient relationship. Non verbal technique involves a variety
of body language, manures, including gestures, facial expressions, body positions, tone
of voice, use of touch, appearance and active listening
TERMINATION
The interview concludes when the data base is obtained or when the nurse determines
that the client is not able to continue. Informing the client that the interview will be
ending shortly, preparing the client for conclusion. At this point no new material should
be introduced by the nurse
OBSERVATION
It is used to gather the information using the five senses and instruments
PHYSICAL EXAMINATIONS

Systemic data collections to detect health problems using unit of measurements physical
examination technique and interpretation of laboratory results the assessment can be
done by cephalocodal approach or body system approach
TECHNIQUES
INSPECTION
It is the visual examination of the client
GUIDELINES FOR EFFECTIVE INSPECTION

Be systematic
Fully expose the area to be inspected and cover the other parts
Use good light preferably natural light
Maintain comfortable room temperature
Observe color symmetry and shape of movement
Compare bilateral structures for similarities and differences

PALPATION
Palpation uses the sense of touch to assess various parts of the body and helps to
confirm findings that are noted on inspection. The hands especially the finger tips are
used to assess skin temperature, to check pulse texture moisture etc
TYPES OF PALPATION
LIGHT PALPATION to check muscle tone and assess for tenderness
DEEP PALPATION to identify abdominal organs and abdominal mass
PERCUSSION
Percussion is the striking of the body surface with short sharp strokes inorder to produce
palpate vibrations and characteristics sound. It is used to determine the location size and
density of the underlying structures to determine the presence of air or fluid in a body
surface and to elicit tenderness
Types of percussion
Direct percussion percussion in which one hand is used and the striking finger of the
examiner touches the surface being percussed
INDIRECT PERCUSSION percussion in which two hands are used and the plexer strikes
the finger of the examiners other hand which is in contact with the body surface being
percussed
BLUNT PERCUSSION percussion in which the ulnar surface of the hand or fist is used in
place of the fingers to strike the body surface either directly or indirectly
AUSCULTATION
Auscultation is listening to the sounds produced inside the body. These include breath
sounds, heart sounds, vascular sounds and bowel sounds. It is used to detect the

presence of normal and abnormal sounds and to assess them in terms of loudness, pitch,
quality, frequency and duration
COMPONENS OF NURSING HISTORY TAKING
Biographic data Name, address, age, marital status, occupation, religion
Reason for visit chief complaints: primary reason why client seeks consultation or
hospitalization
History of present illness includes usual health status, chronological story, family
history, disability assessment
Past health history includes all previous immunizations and experiences with illness
Family history reveals risk factors for certain diseases
Review of systems review of all health problems by body systems
Life styles includes personal habits, diet sleep or rest patterns, activity of daily living,
recreation and hobbies
Social data include family relationship ethnic and educational background economic
status home and neibourhood conditions
Psychological data information about clients emotional state
Pattern of health care includes all health care resources hospitals clinics health centers
family doctors
VALIDATION OF DATA
The act of double checking or verifying data to confirm that it is accurate and complete.
Validation of data is the process of confirming and verifying that the subjective and
objective data collected are reliable and accurate
STEPS IN VALIDATION
Deciding whether the data require validation
Determining the ways to validate the data
Identifying the areas where the data are missing
PURPOSE OF DATA VALIDATION

Ensure the data collection is simple

Ensure that objective and subjective data agree
Obtain additional data that may have been overlooked
Avoid jumping to conclusions
Differentiate clues and inferences

METHODS OF VALIDATION
Recheck your own data with repeated assessments
Clarify data with the client by asking additional questions

 Verify the data with another health care personnel

Compare your objective findings with subjective findings to uncover discrepancies
ORGANIZATIION OF DATA
It uses a written or computerized format that organizes assessment data systematically
COMMUNICATE RECORD AND DOCUMENT DATA
Nurses record all data collected about clients health status
Data are recorded on a factual manner not as interpreted by the nurse
Recording subjective data in clients word, restating in other words what the client
says might change its original meaning
PURPOSE OF DOCUMENTATION
Provides a chronological source of clients assessment data and a progressive
record of clients assessment findings that outline the clients course of care
Ensure that the information about the client and family is easily accessible to
members of health care team
Establishes a basis for screening and validation proposed diagnosis
Acts as a source of information to help diagnosis
Provides access to significant epidemiological data for future investigations
research and educational endeavors
GUIDELINES FOR DOCUMENTATION

Document legibly or print neatly in unerasable ink

Use correct grammar and spelling
Avoid wordiness that creates rudency
Avoid recording the word normal for normal findings
Record complete information and details for the clients symptoms or experiences
Include additional assessment content when applicable
Use phrases instead of sentences to record data

COMMON PROBLEMS OF DATA COLLECTION

Irrelevant or duplicate data collected

Erroneous or misinterpreted data collected
Too little data acquired from the client
Poor documentation from staff
Conflicting data
Language barrier
Insufficient time
Lack of equipment

SUMMARY
In this topic we have discussed about identification of health Illness problems, definition
of assessment types of assessment, steps of assessment sources of data methods of
data collection components of nursing history and problems of data collection

CONCLUSION
The nursing process applied to the care of all client systems including individuals
families groups or communities. Use of the process allows the nurse to differentiate their
practice from that of physicians and other health care professionals. When nurses think
critically the client becomes an active participant and the ultimate outcome is a
comprehensive individualized approach to care

RESEARCH ABSTRACT

A study was conducted to test the efficacy of structured symptom assessment on

level and rate of change in symptom distress over time on Outpatient oncology
offices and clinics in California. 48 subjects newly diagnosed with advanced lung
cancer, predominantly non-small cell was selected. Most subjects received
chemotherapy, 50% were women, and their average age was 62 years. 190
observations were analyzed. . Both groups completed the Symptom Distress Scale
(SDS) monthly. After bivariate screening of potential predictors, a multivariate
regression model for level and rate of change in SDS scores was created. And they
found that Systematic use of structured symptom assessment forestalled
increased symptom distress over time. Chemotherapy lessened symptom distress,
but the impact diminished with time. Subjects with more depression and greater
functional limitations had greater symptom distress.
Nursing pain assessments are influenced by the length of available tools, patient
characteristics, patient pathology, concern about addictive behavior, and
characteristics of the nurse. The relationship among these variables was explored
in a sample of community hospital nurses (N = 59) and ONS members (N = 19).
Although a number of interesting similarities were found in the two groups, age,
professional and continuing education, and care setting appear to be related to
differences in pain assessment practices. Implications for practice, research, and
education include teaching nurses to: assess factors related to quality of life in the
pain experience, assess and validate data from families, assess coping skills, and
teach patients to use behavioral pain management strategies. The findings also
suggest that further study is needed concerning the relationship between personal
beliefs and experiences and the assessment and management of pain.
Membership in professional organizations appears to be associated with
comprehensive approaches to the assessment and management of cancer and
pain should be addressed in further research.

BIBILIOGRAPHY
B T BASAVANTHAPPA,Fundamentals Of Nursing, first edition, Jaypee publishers;
page no:200-210
HELENHARKAREADER MARY ANN HOGAN, Fundamentals of nursing, second
edition, Saunders publishers, page no:92-104
POTTER PERRY, Fundamentals of nursing, sixth edition, Mosby Publishers, page
no:278-294
SHABEER P BASHEER. S YASEEN KHAN,A Concise Text Book Of Advanced nursing
Practice, EMMENSE Publishers page no:504-510
WILSON GIDDENS, Health Assessment For Nursing Practice ,fourth edition Mosby
Publishers, page no:14-12
JOURNAL
INDIAN JOURNAL OF HOLISTIC NURSING volume 5 , September 2009, page no:29
THE NURSE INTERNATIONAL volume 2, number 3, May June 2010, page no:14-15
INTERNET
www.google.co.in/url?sa=t$rit=j$q
En.wikipedia.org/wiki/nursing process