4 Types of Assessment:
a. Initial assessment – assessment performed within a specified time on admission
Ex: nursing admission assessment
b. Problem-focused assessment – use to determine status of a specific problem identified in an earlier assessment
Ex: problem on urination-assess on fluid intake & urine output hourly
c. Emergency assessment – rapid assessment done during any physiologic/physiologic crisis of the client to identify life threatening problems.
Ex: assessment of a client’s airway, breathing status & circulation after a cardiac arrest.
d. time-lapsed assessment – reassessment of client’s functional health pattern done several months after initial assessment to compare the clients current status to baseline data previously obtained.
1. Collection of data
2. Validation of data
3. Organization of data
4. Analyzing of data
5. Recording/documentation of data
Assessment = Observation of the patient + Interview of patient, family & SO + examination of the patient + Review of medical record
I. Collection of data
gathering of information about the client
includes physical, psychological, emotion, socio-cultural, spiritual factors that may affect client’s health status
includes past health history of client (allergies, past surgeries, chronic diseases, use of folk healing methods)
includes current/present problems of client (pain, nausea, sleep pattern, religious practices, meds or treatment the client is taking now)
Types of Data:
a. Subjective data
also referred to as Symptom/Covert data
information from the client’s point of view or are described by the person experiencing it.
information supplied by family members, significant others, other health professionals are considered subjective data.
Example: pain, dizziness, ringing of ears/Tinnitus
a. Objective data
also referred to as Sign/Overt data
those that can be detected, observed or measured/tested using accepted standard or norm....