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22 Cards in this Set
- Front
- Back
Assessment |
Collecting, validating, organizing, recording data about health status. Evaluation of patients health status. Orderly systematic framework for nursing care.. |
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Activities during assessment /components of assessment |
1. Collecting data 2.verifying /validating data |
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Types of data |
A. Subjective B. Objective |
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Collecting Data |
-Interviewing and physical examinations Involves gathering info about the patient |
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Factors for collecting data |
Physical, physiological, emotional, socio-cultural, spiritual, sexual. The whole wholistic care |
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Subjective (symptoms) covert data |
Percieved by the client. Can be describe only by the persons experience. |
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Objective (signs) overt data |
Can be observed and measured by the examiner |
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4 types of assessment |
1.Problem focused assessment 2. Initial assessment 3. Time lapsed assessment. 4.Emergency assessment. |
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Problem focused assessment |
On going (hourly assessment) |
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Initial assessment |
Nursing admin assessment |
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Time lapsed assessment |
After several mo. Reassessment |
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Emergency assessment |
Identification of life threatening assessment. |
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Methods of data collection |
1.Interview 2 observations |
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Interview |
It is a planned purposeful conversation, taking the history of the patient. |
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2 types of interview |
1.Directive 2.non directive |
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Directive |
Asking specific questions |
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Non directives |
Client is in control of the conversation |
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Sources of data |
1. Primary source 2. Secondary source |
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Primary source (direct source) |
Client |
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Secondary source (indirect) |
Data from other source other than the client |
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Verifying /validating data |
Making sure any obtained data is timed and accurate. |
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Purpose of verifying data |
1. To ensure the assessment is complete 2. To ensure the ends objective data agrees. 3. To obtain overlooked data. 4. To avoid jumping into conclusions. |