Download - 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!