ALLANNA Flashcards
First phase in the nursing process
Assessment
Systematic gathering of relevant and important patient data
Assessment
Systematic gathering of relevant and important patient data; nurses use data to:
•Identify health problems
•Plan nursing care
•Evaluate patient outcomes
Is the first step in the nursing process and includes systematic collection verification organization interpretation and documentation of data for used by healthcare professional
Assessment
5 Elements of the assessment process
Data collection
Data verification
Data organization
Data interpretation
Data documentation
Is the process of gathering information about client family or community health status
Data collection
What are the three ways in collecting data
Interview
Observation
Physical examination
Validate data with client and significant others
•Compare subjective and objective data
•Validate conflicting data
3 ways to Organize and record data
•Initial assessment
•Ongoing assessment
•Special purpose assessment
Used printed form (admission database)
Initial assessment
Use nursing model to organize; record on care plan or nursing progress notes
Ongoing assessment
Perform as needed
Special purpose assessment
Is the establish a database about a client’s physical and emotional well-being intellectual functioning social relationships and spiritual condition
Purpose of assessment
Data from the clients point of view and include feelings perceptions and concerns
Subjective data
This data (also referred to as symptoms) are obtained through interview with a client
Subjective data
They are called _________data because they rely on the feelings or opinions of the person experiencing them and cannot be readily observed by another
Subjective
Sometimes called covert data or symptoms
Subjective data
Not measurable or observable
Subjective data
Can be obtained only from what the client’s verbalized
Subjective data
Data from significant others
Subjective data
Include clients: thoughts, beliefs, feeling, sensations, perception of self and health.
Subjective data
Client data include information that the client communicates concerning perceptions of his or her own health status as well as specific observation made by the nurse
COLLECTING DATA
Observable and measurable (quantitative) data that are obtained through observation standard assessment techniques performed during the physical examination and laboratory and diagnostic testing
Objective data
This data also (called signs) can be seen heard or felt by someone other than the person experiencing them
Objective data
Can be detected by someone other than the client
Objective data
Can be obtained by observing and examining the client
Objective data
Example of this data includes pulse rate, skin color urine, output and result of diagnostic test or x-rays
Objective data
Primary source of data
Client
It is a type of sources of data:
•Family or significant others
Secondary source of data
