*It is systematic and continuous collection, validation and communication of client data as compared to what is standard/norm.
*It includes the client’s perceived needs, health problems, related experiences, health practices, values and lifestyles.
Purpose
To establish a data base (all the information about the client):
-nursing health history
-physical assessment
-the physician’s history & physical examination
-results of laboratory & diagnostic tests material from other health personnel
FOUR Types of Assessment
1. Initial assessment – assessment performed within a specified time on admission
Ex: nursing admission assessment
2. Problem-focused assessment – use to determine status of a specific problem identified in an earlier assessment
Ex: problem on urination-assess on fluid intake & urine output hourly
3. Emergency assessment – rapid assessment done during any physiologic/physiologic crisis of the client to identify life threatening problems.
Ex: assessment of a client’s airway, breathing status & circulation after a cardiac arrest.
4. Time-lapsed assessment – reassessment of client’s functional health pattern done several months after initial assessment to compare the client’s current status to baseline data previously obtained.
Activities
-Collection of data
-Validation of data
-Organization of data
-Analyzing of data
-Recording/documentation of data
Assessment
-Observation of the patient + Interview of patient, family & SO + examination of the patient + Review of medical record
Collection of data
-gathering of information about the client
-includes physical, psychological, emotion, socio-cultural, spiritual factors that may affect client’s health status
-includes past health history of client (allergies, past surgeries, chronic diseases, use of folk healing methods)
-includes current/present problems of client (pain, nausea, sleep pattern, religious practices, meds or treatment the client is taking now)
Types of Data
1. Subjective data
-also referred to as Symptom/Covert data
-Information from the client’s point of view or are described by the person experiencing it.
-Information supplied by family members, significant others; other health professionals are considered subjective data.
-Example: pain, dizziness, ringing of ears/Tinnitus
2. Objective data
-also referred to as Sign/Overt data
-Those that can be detected observed or measured/tested using accepted standard or norm.
-Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin
