ASSESSMENT, ANALYSIS, AND NURSING DIAGNOSIS OF THE ADULT

Assessment is the process of gathering a comprehensive database about the patient’s present, past, and potential health problems, as well as a description of the patient as a whole in his or her environment. It includes a comprehensive nursing history, a physical examination, and laboratory/x-ray data, and it concludes with the formulation of nursing diagnoses.

Subjective Data

Nursing History

The nursing history obtains data for planning and implementing nursing actions.

1. General health information: reason for admission; duration of present illness; previous hospitalization; history of illnesses; diagnostic procedures before admission; allergies-type and severity of reactions; medications taken at home-over-the-counter and prescription medications.


2. Information relative to growth and development: age; menarche-age at onset; heavy menses; dysmenorrhea; vaginal discharge; date of last Pap smear; pregnancies; abortions; miscarriages.


3. Information relative to psychosocial functions: feelings (anger, denial, fear, anxiety, guilt, lifestyle changes); language barriers; family support; spiritual needs; history of trauma/rape.


4. Information relative to nutrition: appetite-normal, changes; dietary habits; food preferences or intolerances; difficulty swallowing or chewing; dentures; use of caffeine/alcohol; weight changes; excessive thirst, hunger, sweating.


5. Information relative to fluid and gas transport: difficulty breathing; shortness of breath; history of cough/smoking; colds; sputum; swelling of extremities; chest pain; palpitations; varicosities; excessive bruising; blood transfusions; excessive bleeding.


6. Information relative to protective functions: skin problems-rash, itch; current treatment; unusual hair loss.


7. Information relative to comfort, rest, activity, mobility: usual activity (activities of daily living [ADL]); present ability and restrictions; rest and sleep pattern; weakness; joint or muscle stiffness, pain, or swelling; occupation; interests.


8. Information relative to elimination: bowel habits; changes-constipation, diarrhea; ostomy; emesis; nausea; voiding-retention, frequency, dysuria, incontinence.


9. Information relative to sensory/perceptual functions: pain-verbal report; quality, location; precipitating factors; duration; limitations in vision (glasses), hearing, touch, smell; orientation to person, place, time; confusion; headaches; fainting; dizziness; convulsions.