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Stephanie Talbot 1 NSG 126: ASSESSMENT: I. ASSESSING: Systematic collection, organization, validation and documentation of data. a. Types: i.

Initial assessment- performed on admission to facility. Purpose: establish a database for problem identification, reference and future comparison. ii. Problem focused- to determine status of a specific problem I.d d in an earlier assessment ex. Hourly assessment of fluid intake, assess abilities perform self-are while assisting client to bathe. iii. Emergency assessment- during any psychological or physiological crisis for the client. Purpose: to I.D life-threatening problems, to I.D new or overlooked problems ex. Assess suicide tendency, assess airway during cardiac arrest. iv. Time lapsed reassessment. Purpose- compare baseline to current status ex. Reassessment of clients fxn. Health patterns in long-term care facility. b. Focus: client s response to a health problem. Includes: i. Clients perceived needs ii. Health problems iii. Related experience iv. Health practices v. Values vi. Lifestyle c. Must have an initial assessment within 24hrs COLLECT DATA: process gathering information about clients health status. Purpose: to form a database containing all of the available information about a client. Includes: 1. Nsg health hx- biographical data, chief complaint, hx present illness, family hx, family hx illness, lifestyle, social data, psychological data, patterns of health are 2. Physical assessment 3. Primary care providers hx and physical exam 4. Results laboratory and diagnostic tests 5. Material contributed from other HCP


<<Should include past and current hx of the problem>> a) Types of Data: 1) Subjective data- a.k.a symptoms or covert data- apparent to client only, includes feelings, values, beliefs, sensations, attitudes and perceptions of health problem. 2) Objective data-a.k.a signs or overt data- are detectable by an observer or can be measured or tested against a standard. b) Sources of data: 1) Primary source-the client 2) Secondary source- every -one else c) Data Collection Methods: 1) Observation 2) Interviewing- directive or nondirective interview (rapport building). Uses open-ended, close-ended and neutral questions. 3) Examining- use head-to toes approach (body systems approach)-assess parts and compares. Or a screening approach (review of systems), is a brief review of essential fxns of various body parts.

Stephanie Talbot 2 NSG 126: ASSESSMENT:




ORAGNIZING DATA: NS uses a written format that organizes assessment data. i. OREM s SELF-CARE MODEL: UNIVERSAL SCR: maintain 1. Air 2. Water 3. Food 4. Elimination 5. Activity and rest 6. Solitude and social interaction 7. Prevention hazards 8. Promotion of normal human functioning ii. MASLOWS HIERARCHY OF NEEDS: cluster data 1. Physiological needs (survival) 2. Safety and security 3. Love and belonging 4. Self-esteem 5. Self-actualization VALIDATING DATA: a. Double checking for accurate and factual data b. Helps NS complete these tasks: i. Ensure assessment data complete ii. Ensure objective and subjective data agree iii. Obtain additional information that might have been overlooked iv. Differentiate between cues and inferences 1. Cue0 subjective/objective data that can be directly observed by nurse, what client says or what nurse sees, hears, feels, smells or measures 2. Inferences- nurses interpretation made based on the cues DOCUMENT DATA: a. Assessment is not complete unless you document the data.