Chapter 7 ATI: The nursing process ASSESSMENT/DATA COLLECTION

Assessment/Data Collection

Assessment/data collection involves the systematic collection of information about the health status of clients to identify needs and additional data to collect. Nurses can collect data during an initial assessment (baseline data), focused assessment, and ongoing assessments.

Methods of data collection

Include observation, interviews with clients and families, medical history, comprehensive or focused physical examination, diagnostic and laboratory reports, and collaboration with other members of the health care team.

To collect data effectively

Nurses must ask clients appropriate questions, listen carefully to responses, and have excellent head-to-toe physical assessment skills. Nurses must employ clinical judgment and critical thinking in accurately recognizing when to collect assessment data. They must recognize the need to collect assessment data prior to interventions.

Subjective data

Nurses collect subjective data (manifestations) during a nursing history. Subjective data includes clients’ feelings, perceptions, and descriptions of health status. Clients are the only ones who can describe and verify their own manifestations.

Objective data

Nurses observe and measure objective data (findings) during a physical examination. Nurses feel, see, hear, and smell objective data through observation or physical assessment of the client.

During this assessment/data collection

The nurse validates, interprets, and clusters data.

Documentation of the assessment data

Must be thorough, concise, and accurate.

Objective Data

An assistive personnel reports that the client walks with a limp.

Objective Data

The client’s skin is consistent with genetic background, warm, and dry.

Objective Data

Respiratory rate is even and unlabored at 22/min.

Subjective Data

The client’s pain rating is 3 on a scale of 0 to 10.

Subjective Data

The client’s partner states, “They had burning leg pain after walking 10 minutes.”

Well done! Objective and subjective data

The nurse should analyze cues to identify objective and subjective data.

Objective data

Includes information the nurse can feel, see, hear, or smell, through observation or physical measurement, such as respiratory rate, skin color, temperature, and characteristics, and observation that the client is walking with a limp.

Subjective data

Includes a client’s feelings, perceptions, and descriptions of health status, such as pain level, description of pain, and contributing factors to pain.

Assessment/Data collection

“I will review the past medical history in the client’s medical record to obtain more information about the client.”​​​​​​​

Assessment/data collection step

The newly licensed nurse uses the assessment/data collection step of the nursing process when reviewing the past medical history on the client’s medical record to obtain more information about the client.

Assessment/Data collection

The newly licensed nurse asks the client to rate the severity of the pain on a scale of 0 to 10.

Assessment/data collection step

The newly licensed nurse uses the assessment/data collection step of the nursing process when asking the client to rate the severity of pain on a scale of 0 to 10 scale.