ï»¿4 Types of Assessment:
a. Initial assessment â€“ assessment performed within a specified time on admission
Ex: nursing admission assessment
b. Problem-focused assessment â€“ use to determine status of a specific problem identified in an earlier assessment
Ex: problem on urination-assess on fluid intake & urine output hourly
c. Emergency assessment â€“ rapid assessment done during any physiologic/physiologic crisis of the client to identify life threatening problems.
Ex: assessment of a clientâ€™s airway, breathing status & circulation after a cardiac arrest.
d. time-lapsed assessment â€“ reassessment of clientâ€™s functional health pattern done several months after initial ...view middle of the document...
Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin
Methods of Data Collection:
a.Â Â Â Interview
a planned, purposeful conversation/communication with the client to get information, identify problems, evaluate change, to teach, or to provide support or counseling.
it is used while taking the nursing history of a client
a.Â Â Â Â Observation â€“ use to gather data by using the 5 senses and instruments.
a.Â Â Â Examination
systematic data collection to detect health problems using unit of measurements, physical examination techniques (IPPA), interpretation of laboratory results.
should be conducted systematically:
a.Â Â Â Â Â Â Cephalocaudal approach â€“ head-to-toe assessment
b.Â Â Â Â Â Body System approach â€“ examine all the body system
c.Â Â Â Â Â Â Review of System approach â€“ examine only particular area affected
Source of data:
a.Â Â Â Â Â Â Primary source â€“ data directly gathered from the client using interview and physical examination.
b.Â Â Â Â Â Secondary source â€“ data gathered from clientâ€™s family members, significant others, clientâ€™s medical records/chart, other members of health team, and related care literature/journals.
In the Assessment Phase, obtain a Nursing Health History â€“ a structured interview designed to collect specific data and to obtain a detailed health record of a client.
Components of a Nursing Health History:
ï‚·Biographic data â€“ name, address, age, sex, martial status, occupation, religion.
Reason for visit/Chief complaint â€“ primary reason why client seek or hospitalization.
ï‚·History of present Illness â€“ includes: usual health status, chronological story, family history, disability assessment.
ï‚·ï€ Past Health History â€“ includes all previous immunizations, experiences with illness.
ï‚·Â Â Â Â Â Â Â Â Family History â€“ reveals risk factors for certain disease diseases (Diabetes, hypertension, cancer, mental illness).
ï‚·Review of systems â€“ review of all health problems by body systems
ï‚·Lifestyle â€“ include personal habits, diets, sleep or rest patterns, activities of daily living, recreation or hobbies.
ï‚·Social data â€“ include family relationships, ethnic and...