Chapter 1: Collecting and Analyzing Data

Diagnosis

analyzing subjective and objective data to make a professional nursing judgment

Assessment

collecting subjective and objective data

initial comprehensive assessment

involves collection of subjective data about the clients perception of his or her health of all body parts of systems, past health history, family history and lifestyle and health practices AS WELL AS objective data gathered during a step-by-step physical examination

ongoing or partial assessment

consists of data collection that occurs after the comprehensive database is established -consists of a mini-overview of the client's body systems and holistic health patterns -determine changes in initial presentation

Planning

determining outcome criteria and developing a plan

focused or problem-oriented assessment

does not replace the comprehensive health assessment -it is performed when comprehensive database exists for a client who comes to the health care agency with a specific concern *focuses on thorough assessment of a particular clients problem

collecting subjective data

-biographical information -history of present health concern: physical symptoms related to each body part -personal health history -family history -health and lifestyle practices

collecting objective data

-physical characteristics (skin color, posture) -body functions (heart rate) -appearance -behavior -measurements -results of lab testing *include the techniques of: inspection, palpation, percussion and auscultation

process of data analysis

1) identify abnormal data and strengths 2) cluster the data 3) draw inferences and identify problems 4) propose possible nursing diagnoses 5) check for defining characteristics of those diagnoses 6) confirm or rule out nursing diagnoses 7) document conclusions

steps of health assessment

1) collection of subjective data 2) collection of objective data 3) validation of data 4) documentation of data -clients basic biographical data -activities of daily living

Evaluation

assessing whether outcome criteria have been met and revising the plan as necessary.

Implementation

carrying out the nursing plan

Emergency Assessment

very rapid assessment performed in life-threatening situations *example -> ABC's: airway, breathing and circulation (during suspected cardiac arrest)