Collection of Subjective Data Through Interview /Health History

Introduction

Assessment: Step One of the Nursing Process

❖ First & most critical phase of the nursing process.

❖ If data collection is inadequate or inaccurate, incorrect nursing judgments may be made that
adversely affect the remaining phases of the process: diagnosis, planning, implementation, & evaluation.

❖ Although the assessment phase of the nursing process precedes the other phases, the assessment is
ongoing & continuous throughout all phases of the nursing process.

❖ Thus, health assessment is: Gathering information about the health status of the client Analyzing &
synthesizing that data Making judgments about the effectiveness of nursing interventions

Evaluating client care outcomes

❖ The nursing process should be thought of as circular, not linear.

2 ASPECTS OF HEALTH ASSESSMENT:

1. Nursing Health History - a collection of data that can be used to make judgments, promote wellness,
and teach about nutrition, self-examinations & health screenings.

2. Physical Examination - Carried out systematically Cephalocaudal or head-to-toe approach

TYPES OF DATA:

A. SUBJECTIVE DATA

o Symptoms or covert data

-apparent only to the person affected.

B. OBJECTIVE DATA

o Signs or overt data

-detectable by an observer
-can be measured, tested