unit 1a Flashcards
the first and most critical step of the nursing process and accuracy of assessment data affects all other phases of the nursing process.
Assessment
phases of the nursing process
assessment diagnosis planning implementation evaluation
Collecting subjective & objective data
Assessment
Analyzing subjective & objective data to make a professional judgment
diagnosis
Determining outcome criteria & developing a plan
planning
Carrying out the plan
implementation
Assessing whether outcome criteria have been met & revising the plan as necessary
evaluation
the gathering of information about a patient’s physiological, psychological, sociocultural, developmental & spiritual status
assessment
Purpose: to collect subjective & objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment
assessment
basic types of assessment
- Initial Comprehensive Assessment
- Ongoing or Partial Assessment
- Focused or Problem - Oriented Assessment
- Emergency Assessment
collection of subjective data about the client’s perception of ALL body parts or systems, past health hx, family hx & lifestyle & heath practices plus gathering of objective data during a step-by-step physical examination
Initial Comprehensive Assessment
data collection after comprehensive assessment
Ongoing or Partial Assessment
any problems that were initially detected in the client’s body system are reassessed in less-depth to determine any major
changes from the baseline data
Ongoing or Partial Assessment
thorough assessment of a particular client problem & does not cover areas not related to the problem
Focused Or Problem - Oriented Assessment
Very rapid assessment performed in life threatening situations (e.g. choking. drowning)
Emergency Assessment
an immediate diagnosis is needed to provide prompt treatment
Emergency Assessment
FOUR (4) MAJOR STEPS OF HEALTH ASSESSMENT
Collection of Subjective Data
Collection of Objective Data
Validation of Data
Documentation of Data
data which include sensations or symptoms, feelings, perceptions desires, preferences, beliefs, ideas, values & personal information that can be elicited & verified ONLY by the client
COLLECTING SUBJECTIVE DATA
Method used to obtain data: client interview
COLLECTING SUBJECTIVE DATA
Major areas of subjective data:
a. Biographical information
b. Physical symptoms related to each body part or system c. Past health history
d. Family history
e. Health & lifestyle practices
Includes data:
directly obtained by the nurse / examiner through observation
& PE
observed by family or SOs about the client
from client’s health record
COLLECTING OBJECTIVE DATA
Major areas of objective data
a. physical characteristics (e.g. skin color & posture) b. body functions (e.g. HR, RR)
c. appearance
d. behavior
e. measurements (e.g. ht, wt) f. laboratory results
collection of subjective data about the client’s perception of ALL body parts or systems, past health hx, family hx & lifestyle & heath practices plus gathering of objective data during a step-by-step physical examination
Initial Comprehensive Assessment
data collection after comprehensive assessment
Ongoing or Partial Assessment
Gathering information (e.g. biographical data such as age, sex, religion, occupation & important documented information) before actually meeting the client
PREPARING FOR THE ASSESSMENT
the process of confirming or verifying that the subjective data & objective data you have gathered are reliable & accurate as well as complete
VALIDATION OF DATA
Methods of Validation
a. recheck your own data
b. clarify data w the client (ask additional questions)
c. verify w another healthcare professional
d. compare objective from subjective findings
primary reason: to provide the HC team w/a database that becomes the foundation of care for the client helps to identify health problems, formulate nursing diagnoses & plan
DOCUMENTATION OF DATA
Assessment integral part of nursing ever since the days of Nightingale
Past
Nurses relied on their natural senses
past
Role of nurses in health assessment more prevalent today
present
Role of nurses in health assessment more prevalent today
present
increased specialization & diversity of assessment skills
future
Nurses roles to vastly grow w nurses who have strong
assessment & client teaching abilities
future
