Podcast
Questions and Answers
Which of the following is a secondary source of data?
Which of the following is a secondary source of data?
What is considered objective data in healthcare?
What is considered objective data in healthcare?
In an interview, which approach is highly structured and involves direct questions?
In an interview, which approach is highly structured and involves direct questions?
During an interview, which stage focuses on the initial interaction and setting the tone?
During an interview, which stage focuses on the initial interaction and setting the tone?
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Which of the following is NOT a technique used in a physical examination for data collection?
Which of the following is NOT a technique used in a physical examination for data collection?
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How does a nurse primarily organize assessment data?
How does a nurse primarily organize assessment data?
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What is the purpose of validating data during the assessment phase?
What is the purpose of validating data during the assessment phase?
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Which of the following is the primary task of the diagnosis phase in the nursing process?
Which of the following is the primary task of the diagnosis phase in the nursing process?
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What is the official NANDA definition of a nursing diagnosis?
What is the official NANDA definition of a nursing diagnosis?
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What is the purpose of documenting data during the assessment phase?
What is the purpose of documenting data during the assessment phase?
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Which of the following is an example of a risk nursing diagnosis?
Which of the following is an example of a risk nursing diagnosis?
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What is the purpose of using NANDA guidelines during the diagnosis phase?
What is the purpose of using NANDA guidelines during the diagnosis phase?
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Which type of data can be described only by the person affected?
Which type of data can be described only by the person affected?
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When is an emergency assessment typically performed?
When is an emergency assessment typically performed?
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Which type of data can be measured or tested against an accepted standard?
Which type of data can be measured or tested against an accepted standard?
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What is the purpose of a problem-focused assessment?
What is the purpose of a problem-focused assessment?
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When is a time-lapsed reassessment typically performed?
When is a time-lapsed reassessment typically performed?
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What distinguishes subjective data from objective data?
What distinguishes subjective data from objective data?
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Study Notes
Types of Nursing Assessments
- Initial nursing assessment: performed within a specified time after admission to establish a complete database for problem identification
- Problem-focused assessment: determines the status of a specific problem identified in an earlier assessment
- Emergency assessment: performed during emergency situations to identify life-threatening situations
- Time-lapsed reassessment: compares the client's current health status with previously obtained data
Data Collection
- Includes health history, physical examination, laboratory and diagnostic test results, and material contributed by other health personnel
- Two types: subjective data and objective data
- Subjective data: symptoms or covert data, clear only to the person affected (e.g., itching, pain, feelings of worry)
- Objective data: signs or overt data, detectable by an observer or measurable against an accepted standard (e.g., vital signs, laboratory results)
Validation and Documentation of Data
- Validation: verifying the accuracy and completeness of gathered information
- Documentation: recording client data, essential for accuracy and completeness
Nursing Diagnosis
- Definition: a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response
- Status of nursing diagnosis: actual, health promotion, and risk
- Actual diagnosis: a client problem that exists at the time of assessment
- Health promotion diagnosis: relates to clients' preparedness to improve their health condition
- Risk nursing diagnosis: a clinical judgment that a problem does not exist, but risk factors indicate a potential problem
Sources and Methods of Data Collection
- Primary source: the client
- Secondary sources: family members, health professionals, records, laboratory and diagnostic results
- Methods: observation, interview, and examination
- Observation: gathering data using the senses (vision, smell, hearing)
- Interview: a planned communication or conversation with a purpose (directive and nondirective approaches)
- Examination: a systematic data collection method to detect health problems using techniques of inspection, palpation, percussion, and auscultation
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Description
Learn about different types of nursing assessments including initial nursing assessment, problem-focused assessment, and emergency assessment. Understand the purpose and procedures for each type of assessment.
