Assessment and Nursing Diagnosis

Nursing assessment at all levels of analysis (individuals, families and communities), consist of subjective data from the person or persons and objective data from diagnostic tests and other sources. Assessments of individuals consists of a health history (subjective data) and a physical axamination (objective data) (Weber and Kelly, 2007). Assessments of families consist of obtaining specific information from the family (subjective data) and observing family interaction (objective data) (Wright and Leahey, 2005). Assessment of communities consist of obtaining information from key informans within the community (subjective data) and statistical data (objective data) (Anderson and McFarland, 2006).

There are two types of assessment that are done to generate accurate nursing diagnoses: comprehensive and focused. Comprehensive assessment cover all aspects of a nursing assessment fremework such as the 11 functional health patterns to determine the health status of the individual, family, or community. Comprehensive assessment of individuals are done, for example, when admitting patient to a hospital or home care services. Focused assessments focus on a particular issue or concern, such as pain, sleep, or respiratory status. Focused assessments are done when specific symptoms need to be explored further, e.g., a person says “I am having difficulty with breathing”, or something generates increased risk of a particular problem, e.g., when a person needs the medication of coumadin, there is increased risk of bleeding.

The goals for a nursing assessment are that:

• It focuses on the data needed to identify human responses and experiences
• It is conducted in partnership with the idividual, family or community, wherever possible
• The findings are based on reseach and other evidence.