ASSESSMENT

Collect data: review of the clinical

record
Interview
Health history
Physical Examination
Functional Assessment
Consultation
Review of the Literature
Assessment includes gathering and
analyzing client data and involves
appraising areas which the client
might require nursing care or
assistance to meet basic needs or
higher level needs.
Provides direction for focus of
individualized care
 Assessment
Systematically gather data; assess the client’s
status from the admission history, PE, and
diagnostic test
Underline any abnormal data or note on separate
pad
Interview client regarding perceptions of
conditions and need priorities
Organize and group areas of concern
Determine client’s ability to meet identified
needs, match client strengths and support needs