Nursing Process Reviewer Flashcards
What is the Primary of Sources of Data?
Client
What are the Secondary in Sources of Data?
- Family/significant other
- Other health care professionals
- Medical records
- Interdisciplinary conferences, rounds, and consultations
- Results of diagnostic tests
- Relevant literature
- Nurse’s knowledge and experience
First phase in the nursing process
Assessment
Systematic gathering of relevant and important patient data;
a. Identify health problems
b. Plan nursing care
c. Evaluate patient outcomes
Is the process of gathering information about client, family or community health status.
Data Collection
Elements of The Assessment Process
- Data Collection
- Data Verification
- Data Organization
- Data Interpretation
- Data Documentation
- Interview
- Observation
- Physical examination
Collect Data
- Compare subjective and objective data
- Validate conflicting data
Validate data with client and significant others
- Initial assessment: Use printed forms, (admission database)
- Ongoing assessment: Use nursing model to organize; record on care plan or nursing progress notes
- Special purpose assessment: Perform as needed.
Organize and record data
To establish a database about client’s physical and emotional well-being, intellectual functioning, social relationships, and spiritual condition.
Purpose of Assessment
Types of Data
- Subjective Data
- Objective Data
Observable and measurable (quantitative) data obtained through observation, standard assessment techniques performed during the physical examination, and laboratory and diagnostic testing.
Objective Data
These data (also called signs) can be seen, heard, or felt by someone other than the person experiencing them.
Objective Data
Data from the client’s point of view and include feelings, perceptions, and concerns.
Subjective Data
These data (also referred to as symptoms) are obtained through interviews with the client.
Subjective Data
Can be detected by someone other than the client
Objective Data
Sometimes called covert data or symptoms
Subjective Data
Not measurable of observable
Subjective Data
Can be obtained by observing and examining the client
Objective Data
Give an example of Objective Data
Pulse rate
Skin color
Urine output
Result of diagnostic tests or X-rays.
Can be obtained only from what the clients verbalized
Subjective Data
Includes 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 observations made by the nurse.
Types of Data
Through assessment, the nurse determines the client’s functional abilities and the absence or presence of dysfunction.
Purpose of Assessment
