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)
