CHAPTER 1 – Nurse’s Role in Health Assessment – Collecting and Analyzing Data

Nursing - the protection, promotion, and optimization of health and abilities through the diagnosis and
treatment of human responses
The registered nurse collects comprehensive data pertinent to the patient's health or situation
To accomplish pertinent and comprehensive data collection the nurse: CHIESD
To accomplish this, the registered nurse: DVD
Assessment - the first and most critical phase of the nursing process
Assessment - ongoing and continuous throughout all phases of the nursing process
The phases of the nursing process in order: assessment, diagnosis, planning, implementation,
evaluation
Assessment - collecting subjective and objective data
Diagnosis - analyzing subjective and objective data to make a professional nursing judgement
Planning - determining outcome criteria
Implementation - carrying out the plan
Evaluation - assessing weather outcome criteria have been met and revising the plan as necessary
Nursing assessment - collective subjective and objective data to determine a client's overall level of
functioning in order to make a professional clinical judgment
Medical assessment - focuses primarily on the client's physiologic development status
Four basic types of assessment:

• initial comprehensive assessment

• ongoing or partial assessment
• focused or problem-oriented assessment
• emergency assessment
Family history - A record of health information about a person and his or her close relatives
Past medical history - a narrative or record of past events and circumstances that are or may be relevant
to a patient's current health
Ongoing or partial assessment - consists of data collection that occurs after the comprehensive data
based is established
Focused or problem-oriented assessment - consists of a thorough assessment of a particular client
problem and does not cover areas not related to the problem
Emergency assessment - very rapid assessment performed in life threatening situations
Four major steps of assessment phase of the nursing process:

• collection of subjective data

• collection of objective data
• validation of data
• documentation of data

Collection of subjective data: BPPFH

Collection of objective data: PBABMR
Validation assessment data
- Crucial part of assessments that often occurs along with collection of subjective and objective
data
- it serves to ensure that the assessment process is not ended before all relevant data have been
collected
- Helps prevent documentation of inaccurate data
Documenting data
- Thorough and accurate documentation is vital to ensure that valid conclusions are made
What is the name of the teacher? Mark Kevin A. Celeres
State the phase of the nursing process in order: assessment, diagnosis, planning, implementation,
evaluation
what is the meaning of IPPA – inspection, palpation, percussion, auscultation
CHAPTER 4 – Validating and Documenting Data

Validation of data - verify that subjective and objective data are accurate and reliable
Steps of validation: DDI
- Decide
- Determine
- Identify

Data requiring validation

- Discrepancies
- Abnormal / inconsistent data

Methods of validation: RCVC

- Repeat
- Clarify
- Verify
- Compare

Identification of areas where data are missing: GE

- Grouping data
- Establishing initial data base

Documenting data is required by: NAI

- Nursing practice act
- Accreditation
- Institutional agency

Purpose of documentation:
- promote effective communication among multidisciplinary health team members
- To facilitate safe and efficient client care

Assessment forms for documentation:

• Initial assessment form

• Frequent or ongoing assessment form
• Focused or specialty area assessment form
Initial assessment form - nursing admission or admission database
Frequent or ongoing assessment form - flow charts that help staff to record and retrieve data
Focused or specialty area assessment form - focused on one major area of the body for clients who
have a particular problem

SBAR - situation, background, assessment, recommendation

COLDSPA - character, onset, location, duration, severity, pattern, associated factors