Nursing Assessment Types

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