HA UNIT 1A: The Nurse’s Role in Health Assessment

Before answering, switch the settings to answer with definitions instead of terms, and make sure to shuffle the questions💕.

The gathering of information about a patient's physiological, psychological, sociocultural, developmental, and spiritual status.

Assessment

The Nursing Process

1. Assessment

2. Diagnosis

3. Planning

4. Implementation

5. Evaluation

In the nursing process, what is Diagnosis?

Analyzing subjective & objective data to make a professional judgment.

In the nursing process, what is Planning?

Determining outcome criteria & developing a plan.

In the nursing process, what is Implementation?

Carrying out the plan.

In the nursing process, what is Evaluation?

Assessing whether outcome criteria have been met & revising the plan as necessary.

4 Types of Assessment

1. Initial Comprehensive Assessment

2. Ongoing or Partial Assessment

3. Focused or Problem-Oriented Assessment

4. Emergency Assessment

What is Initial Comprehensive Assessment?

Collection of subjective data about the client's perception of all body parts or systems and gathering objective data during a step-by-step physical examination.

What is Ongoing or Partial Assessment?

Data collection after the comprehensive assessment to reassess any problems initially detected in the client's body system.

What is Focused or Problem-Oriented Assessment?

Assessment that focuses on a particular client problem and does not cover areas not relevant to the problem.

What is Emergency Assessment?

A very rapid assessment performed in life-threatening situations to provide an immediate diagnosis for prompt treatment.

Examples of Emergency Assessment

ABC’s

1. Airway

2. Breathing

3. Circulation

What are the 4 major steps of Health Assessment?

1. Collection of Subjective Data

2. Collection of Objective Data

3. Validation of Data

4. Documentation of Data

Data that includes sensations, feelings, perceptions, desires, beliefs, and personal information that can only be verified by the client.

Subjective Data

What is the method used to obtain subjective data?

Client Interview

What are the major areas of information collected in subjective data?

biographical information, physical symptoms related to each body part or system, past health history, family history, health and lifestyle practices.

Data that includes information directly obtained by the nurse through observation and physical examination P.E., observed by family or S/Os about the client, and from client’s health record.

Objective Data

What are the major areas of information collected in objective data?

physical characteristics (ex. skin color, posture), body functions (ex. HR, RR), appearance, behavior, measurements (ex. height and weight), laboratory results.

The process of confirming that the subjective and objective data gathered are reliable, accurate, and complete.

Validation of Data

What are the other methods in validating data?

rechecking your own data, clarifying data with client (additional questions), verifying with another healthcare professional, and comparing objective and subjective findings.

Providing the healthcare team with a database that becomes the foundation of care for the client.

Documentation of Data