Unit 2: Objective 2: Concept of Assessment & the Nursing Process
Unit 2: Objective 2: Unit Outcome 2:
Discuss the concept of assessment as the first phase of the nursing process -: -
Assessing:
-collecting, organizing, validating, & documenting client data
-systematic & continuous process carried out during all phases
-purpose: establish database about client's response to health concerns or illness &
ability to manage health care needs
Assessing -: -systematic & continuous collection, organization, validation, &
documentation of data (information)
-continuous process carried out during all phases of nursing process
-all phases depend on accurate & complete collection of data
-focus on client's responses to health problem
-nurses should think critically about what to assess
Assessment Phase -: -Collect patient data
-Identify priority areas to be assessed
-Determine types of data needed
-Establish a database
-Analyze data & patient's symptoms
Types of Assessment -: 1. Initial Nursing Assessment
2. Problem Focused Assessment
3. Emergency Assessment
4. Time Lapsed Reassessment
Initial Assessment -: Time Performed:
-performed within specified time after admission to an agency
Purpose:
-establish complete database for problem identification, reference, & future comparison
Example:
-nursing admission assessment
Problem Focused Assessment -: Time Performed:
-ongoing process integrated with nursing care
Purpose:
-determine status of specific problem identified in earlier assessment
Example:
, -hourly assessment of client's fluid intake & urinary output in an ICU
-assessment of client's ability to perform self care while assisting a client to bathe
Emergency Assessment -: Time Performed:
-during any physiological or psychological crisis of client
Purpose:
-identify life threatening problems
-identify new or overlooked problems
Example:
-rapid assessment of person's airways, breathing status, & circulation during cardiac
arrest
-assessment of suicidal tendencies or potential for violence
Time Lapsed Reassessment -: Time Performed:
-several months after initial assessment
Purpose:
-compare client's current status to baseline data previously obtained
Example:
-reassessment of client's functional health patterns in a home care, outpatient setting, or
hospital, at shift change
Collecting Data -: -data collection is the process of gathering information about
client's health status
-must be systematic & continuous to prevent excluded significant data
-refer to client's changing health status
-client data should include past history as well as current problems
-to collect data accurately, client & nurse must actively participate
Database -: -contains all information about client
-includes:
-nursing health history
-physical assessment
-primary care provider's history
-primary care provider's physical examination
-results of laboratory & diagnostic tests
-material contributed by other health personnel
Types of Data -: 1. Subjective Data:
-referred to as symptoms or covert data
-what the patient tells you
-can only be described & verified by person affected
Unit 2: Objective 2: Unit Outcome 2:
Discuss the concept of assessment as the first phase of the nursing process -: -
Assessing:
-collecting, organizing, validating, & documenting client data
-systematic & continuous process carried out during all phases
-purpose: establish database about client's response to health concerns or illness &
ability to manage health care needs
Assessing -: -systematic & continuous collection, organization, validation, &
documentation of data (information)
-continuous process carried out during all phases of nursing process
-all phases depend on accurate & complete collection of data
-focus on client's responses to health problem
-nurses should think critically about what to assess
Assessment Phase -: -Collect patient data
-Identify priority areas to be assessed
-Determine types of data needed
-Establish a database
-Analyze data & patient's symptoms
Types of Assessment -: 1. Initial Nursing Assessment
2. Problem Focused Assessment
3. Emergency Assessment
4. Time Lapsed Reassessment
Initial Assessment -: Time Performed:
-performed within specified time after admission to an agency
Purpose:
-establish complete database for problem identification, reference, & future comparison
Example:
-nursing admission assessment
Problem Focused Assessment -: Time Performed:
-ongoing process integrated with nursing care
Purpose:
-determine status of specific problem identified in earlier assessment
Example:
, -hourly assessment of client's fluid intake & urinary output in an ICU
-assessment of client's ability to perform self care while assisting a client to bathe
Emergency Assessment -: Time Performed:
-during any physiological or psychological crisis of client
Purpose:
-identify life threatening problems
-identify new or overlooked problems
Example:
-rapid assessment of person's airways, breathing status, & circulation during cardiac
arrest
-assessment of suicidal tendencies or potential for violence
Time Lapsed Reassessment -: Time Performed:
-several months after initial assessment
Purpose:
-compare client's current status to baseline data previously obtained
Example:
-reassessment of client's functional health patterns in a home care, outpatient setting, or
hospital, at shift change
Collecting Data -: -data collection is the process of gathering information about
client's health status
-must be systematic & continuous to prevent excluded significant data
-refer to client's changing health status
-client data should include past history as well as current problems
-to collect data accurately, client & nurse must actively participate
Database -: -contains all information about client
-includes:
-nursing health history
-physical assessment
-primary care provider's history
-primary care provider's physical examination
-results of laboratory & diagnostic tests
-material contributed by other health personnel
Types of Data -: 1. Subjective Data:
-referred to as symptoms or covert data
-what the patient tells you
-can only be described & verified by person affected
