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Ch. 15 - Nursing Assessment


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Allows nurse to integrate element of critial thinking to make judgements and take actions based on reason.
Nursing Process
Used to identify, diagnose, and treat human responses to health and illness.
Nursing Process
What are the 5 steps to the nursing process?
1. Assessment
2. Diagnosis (Nursing)
3. Plan
4. Implementation
5. Evaluation
The deliberate and systematic collection of data to determine a client's current and past health status and functional status and to determine the client's present and past coping patterns
2 Steps in assessment:
1. Collection and verification of data from client.
2. Analysis of all data as basis for developing a nursing diagnosis and plan of care.
Information that the nurse acquires through use of the five senses.
Clients' perceptions about their health problems. Only client can provide this type of information.
Subjective data
Observations and measurements made by the data collector, i.e., nurse.
Objective data
Sources of Data:
Family/Significant Other
Health Care Team Members
Medical Records
Other Records
Literature Review
Nurse's Experience
Usually the best source of data (information)
Can supply information about the client's current health status, but also are often able to indicate when changes in the client's status occurred and how the clien'ts functioning was affected.
Family/Significant Others
Provide information about the way the client interactas within the health care environment; the client's reatctionto information, diagnostic procedures, nursing and medical therapies, and how the client responds to visitors.
Health Care Team Memebers
Educational, military, and employment records that contain pertinent health care information.
Other Records
Nursing, medical, and pharmacological readings about a client's illness that helps the nurse complete the assessment database.
Literature Review
Helps nurse learn to ask right questions, choosing those taht yield the most useful information.
Nurse's Experience
Methods of Data Collection
1. Interview
2. Nursing Health History
3. Documentation of History Findings
4. Physical Examination
5. Diagnostic/Laboratory Data
Organized converstation with thte client to obtain the client's health history and information about the current illness.
Phases of and Interview:
1. orientation
2. working
3. termination
Begins with the nurse's introduction to the client, which includes the nurse's name, position, and an explanation of the purpose of the interview.
Orientation Phase
(important in establishing trust and confidence with a client)
When nurse gathers info. about the client's health status.
Working Phase
Nurse summarizes important points an asks the client whether the summary was accuarate, after giving the client a clue that the interview is coming to an end.
Termination Phase
Interview Techniques:
1.Pay attention to environment
2.Client Comfort
3.Good Communication
Questions that prompt client to describe a situation in more than one or two words and leads to a discussion.
Open-ended questions
Active listening techniques such as saying "all right," "go on," or "un-huh," which indicates the nurse has heard what the client said and encourages even further elaboration.
Back Channeling
Takes the information provided in the client's story to more fully describe and identify the client's specific problems.
Problem-seeking interview
Questions that limit the client's answers to one or two words such as "yes" or "no" or a number or frequency of a symptom.
Close-ended questions
Data collected about the client's current level of wellness, including a review of body systems, family and health history, sociocultural history, spiritual health, and mental and emotional reactions to illness.
Nursing Health History
Components of Nursing Health History:
1.Biographical Info.
2.Reason for seeking health care
3. Client Expectations
4. Present Illness or Health Concerns.
5. Health History
6. Family History
7. Environmental History
8. Psychosocial History
9. Spiritual Health
10. Review of Systems
Factual demographic data about the client
Biographical Information
Why client is sekking health care, because the info. contained on the initial admission form may differ from the client's subjective reason for seeking health care.
Reason for seeking health care
Acknowledging what is important to the client who is seeking health care
Client Expectations
Essential and relevant data about the nature and onset of symptoms.
Present Illness or Health Concerns
Client's health care experiences and current health habits
Health History
Data about immediate and blood relatives
Family History
Data about client's home and working environments with emphasis on determining the client's safety.
Environmental History
Data that reveals the client's support system, which may include spouse, children, other family members, and close friends
Psychosocial History
Data that represents the totality of one's being and is difficult to assess quickly.
Spritual Health
Systematic method for collecting data on all the body systems.
Review of systems
Recording the nursing health history, assessment datat in a clear, concise manner using appropriate terminology.
Documentation of History Findings
Vital signs and other objective measurements are taken and all body systems are examined.
Physical examination
Physical Examination Techniques:
inspection, palpation, percussion, auscultation, and olfaction
Can identify or verify alterations questioned ro identified during the nursing health history and physical examination.
Diagnostic or Laboratory Data

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