assessment: point of entry in an ongoing process Flashcards
what is an assessment
collection of data about a person’s health state
what is subjective data
what the person says during history taking
what is objective data
what you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination
what elements form the database
subjective data + objective data+ patient’s record and laboratory studies
what does the information from the database allow the nurse to do
allows nurse to make a clinical judgement or diagnosis about the patient’s health state
etc; response to actual or potential health problems and life processes
what is the key to a health assessment
the organization of assessment based on complete factually based data
why is it important to have an assessment based on factual data
because all healthcare diagnoses, decisions, and treatments are based on the data you gather during an assessment
