Fundamental in nursing

Assessment objective ad subjective data

Definition:

 The systematic and continual gathering, validation, and documentation of

data is known as assessment.
 The nurse obtains information in order to determine the patient's health
state.
 Assessments are done at the start and during the patient's treatment.
 The legitimacy and completeness of the first data collection are critical to
the rest of the nursing process.

Examining the medical record:

 Client records include demographics, prior medical history, diagnostic test

results, and consultations gathered by various members of the healthcare
team.
 Before commencing an assessment, the nurse should review the client's
record to avoid asking the same questions the client has already been asked
and to identify information that needs to be clarified.

Interview:

 An interview is used to collect and convey information, highlight problems

of concern, and provide instruction and help.
 An interview's objectives are to establish a connection with the client and
to gather information.
 There are three primary stages to an interview:
o The purpose of the opening is to establish rapport by eliciting
goodwill and trust; this is frequently accomplished through a self-
 introduction, nonverbal gestures (a handshake), and small talk about
the weather, a local sports team, or a recent current event; the
purpose of the interview is also explained to the client at this time.
o Body: During this phase, the client replies to the nurse's open-ended
and closed-ended inquiries.
o Closing: The interview may be terminated by either the client or the
nurse; nevertheless, it is crucial for the nurse to strive to retain the
rapport and trust that has been established thus far during the
interview process.
 Types of questions
o In a directed interview, closed questions are utilized.
 Re____ brief, truthful responses, such as "Are you in pain?"
 Clients who are very anxious and/or have difficulties speaking
benefit from answers that give just a limited amount of
information.
 In a nondirective interview, open-ended questions are utilized.
o For example, "How have you been sleeping lately?" encourages
customers to communicate and clarify their ideas and feelings.
o Set a broad topic for discussion and promote lengthier responses.
o It's good to use at the beginning of an interview or to shift the
subject.
 Leading questions
o "You don't have any questions concerning your drugs, do you?"
direct the client's response.
o Indicates what type of response is expected.
o It's possible that the client will provide incorrect information in order
to please the nurse.
o Clients' options for conversation topics may be limited.
History of Nursing:

 Information on the impact of the client's disease on everyday functioning

and the client's capacity to cope with the stressor is gathered (the human
response)
 Subjective data
o "Covert data" is a possible term.
o There is nothing that can be measured or observed about it.
o Client (main source), significant others, or medical professionals
(secondary sources).
o "I have a headache," for example, the client says.
 Objective data
o It's possible that this is referred to as "overt data."
o Someone other than the client may be able to discover it.
o Client behavior that is quantifiable and observable is included.
o A blood pressure value of 190/110 mmHg, for example.

Physical examination:

 Observation, examination, auscultation, palpation, and percussion are all

used to acquire data about the bodily systems in a systematic way.
 The following is a body system framework for physical assessment:
o a general evaluation
o The integumentary system
o The head, ears, eyes, nose, and throat are all parts of the human body.
o Axillae and breasts
o Lungs and thorax
o System of the heart and blood vessels
o System of Nerves
o The gastrointestinal system and the abdomen
 o Anus and rectum are two of the most important organs in the human
body.
o System of the genitourinary organs
o System of reproduction
o System of the musculoskeletal system
 Psychosocial examination:
o A useful paradigm for data organization
o Below is a suggested psychosocial evaluation format.
 Vocation/education/financial
 Family & Home
 Social, recreational, spiritual, and cultural factors all play a
role in the lives of people.
 Everyday sexual pursuits
 Psychological Wellness Habits
 Erickson, Freud, Havighurst, Kohlberg, and Piaget's developmental
theories may also be useful in directing data collecting.

Assessment objectives:

1. To create a database, you'll need all of the following information on a

client:
 It contains the following items:
 The nurse's medical history
 Examination of the body
 The background of the doctor
 Laboratory and diagnostic test results
2. Every activity the nurse does for and with the patient includes assessment.
The goal is
 to confirm a diagnosis.
 To lay the groundwork for efficient nursing care.
  It aids in making sound decisions.
 The foundation for a precise diagnosis
 It promotes all-encompassing nursing care.
 To deliver high-quality, cutting-edge nursing care. (1. to data
collection for nursing research; 2. to nursing care evaluation)

Consultation:

 The nurse gathers information from a variety of sources, including primary

(client) and secondary (other sources) (family members, support persons,
healthcare professionals and records)
 In order to obtain the most full and correct information on a customer,
consulting with individuals who can contribute to the client's database is
beneficial.
 Secondary sources of information (any source other than the client) can
help validate information, give information for a client who is unable to do
so, and communicate information regarding the client's status prior to
admittance.

A literature review:

 A professional nurse participates in continuing education to stay up to date

on current health-care facts.
 Reviewing professional publications and textbooks might help you find
more information to support or evaluate your client database.