assessment and data collection

8/9/2019 Assessment and Data Collection

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S S E S S M E N T A N D D A TAC O LLE C T IO N

By: Glaiza Erika O. Luces, RN


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Nursing Assessment

Systematic and continuous collection,

organization and documentation of

data.

A continuous process carried out during

all phases of the nursing process.

Data collected should be relevant to a

particular problem.


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Four different types ofassessment

Initial Assessment

Performed within a specified time

after admission to a healthcare

agency.

To establish a complete database and

reference.


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Problem focused assessment

Ongoing process integrated with

nursing care

To identify the status of a specificproblem identified in an earlier

assessment.


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Time- lapsed reassessment

Several months after initial

assessment

To compare the clients present status

to baseline data previously

obtained.


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Types of data

Subjective data

Symptoms or covert data

Apparent only to the person affected

Objective data

Signs or overt data

Detectable by an observer

Can be measured, or tested


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Constant data

Information that does not change

over time

Variable data

Can change quickly, frequently, or

rarely


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Components of a Nursing HealthHistory

Biographic Data

Chief Complaint or Reason for Visit

History Of Present Illness pqrst

Family history of illness


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Past history

Childhood illnesses

Childhood immunizations

Allergies

Hospitalizations

Medications


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Lifestyle

Personal habits

Diet

Sleep and rest patterns

ADL

Instrumental ADL


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Social data

Family relationships and friendships

Ethnic affiliation Educational history

Occupational history

Economic status Home and neighborhood conditions


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Psychologic Data

Major stressors Usual coping pattern

Communication style

Patterns of health care


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Sources of data

Client - Best source of data, subjective data.

Support people

Family members, friends and care givers

Important source of data if the client is young,

unconscious or confused.

Client records

Information documented by other healthcare

professionals


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Health care professionals verbal

reports

Literature -journals, reference texts,

published studies


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Data collection methods

Observing

Interviewing

examining


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Observing

To gather data using the senses

A conscious, deliberate skill

2 aspects:

Noticing the data

Selecting, organizing and interpreting

the data


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Interview

Planned communication or conversation

with a purpose

To get or give information

Identify problems of mutual concern

Evaluate change, teach, provide support Provide counseling or therapy


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Types of interview

Directive interview

Highly structured

Controlled by the nurse

Elicits specific information

Nurse uses directive questions


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Nondirective interview

Rapport-building interview

Controlled by the client

Rapport understanding between two

or more people.


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Information gathering interview

Combination of non directive and

directive interview


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Types of interview questions

Closed questions

Used in directive interview

Answerable only by Yes or No

Often begin with where, who, what, do ,

is. For patients who are highly stressed and

has difficulty communicating.


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Open-ended questions

Used in non directive interview

Invites client to explore, elaborate,

clarify thoughts or feelings.

Useful in eliciting attitudes and mentalstatus

Often begin with what and how


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Neutral question

A question that the client can answer

without direction or pressure from the

nurse.

Leading question

Closed. Directive. Persuasive.


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HE INTERVIEW AND SETTING


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Factors to be consideredduring interview

Time

When the client is physically

comfortable and free of pain

Place

Well-lighted, well-ventilated room, freeof noise and distractions


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Seating arrangement

Ideal seating arrangement: the nurse

and patient sit in two chairs placed at

right angles to a desk or a table or a

few feet apart with no table.


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Distance

Maintain a 2 to 3 feet distance duringinterview

Language

Avoid medical jargon Translators, interpreters


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Examining

Physical examination

Carried out systematically

Cephalocaudal or head to toe approach Screening examination

Also called review of systems

A brief review of essential functioning of

various body parts or systems


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THANK YOU!

assessment and data collection

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