The document discusses health assessment in nursing. It describes assessment as the systematic collection of client data, which is the first step in the nursing process. The purposes of assessment are to establish a health baseline, determine functional abilities, and form a therapeutic relationship. Types of assessments include initial, comprehensive, problem-focused, ongoing, emergency, and time-lapsed assessments. Data collection methods involve gathering both subjective and objective information from primary and secondary sources like the client, records, and tests. Common methods are observation, interviews, and health histories.
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The document discusses health assessment in nursing. It describes assessment as the systematic collection of client data, which is the first step in the nursing process. The purposes of assessment are to establish a health baseline, determine functional abilities, and form a therapeutic relationship. Types of assessments include initial, comprehensive, problem-focused, ongoing, emergency, and time-lapsed assessments. Data collection methods involve gathering both subjective and objective information from primary and secondary sources like the client, records, and tests. Common methods are observation, interviews, and health histories.
The document discusses health assessment in nursing. It describes assessment as the systematic collection of client data, which is the first step in the nursing process. The purposes of assessment are to establish a health baseline, determine functional abilities, and form a therapeutic relationship. Types of assessments include initial, comprehensive, problem-focused, ongoing, emergency, and time-lapsed assessments. Data collection methods involve gathering both subjective and objective information from primary and secondary sources like the client, records, and tests. Common methods are observation, interviews, and health histories.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as PPT, PDF, TXT or read online from Scribd
The document discusses health assessment in nursing. It describes assessment as the systematic collection of client data, which is the first step in the nursing process. The purposes of assessment are to establish a health baseline, determine functional abilities, and form a therapeutic relationship. Types of assessments include initial, comprehensive, problem-focused, ongoing, emergency, and time-lapsed assessments. Data collection methods involve gathering both subjective and objective information from primary and secondary sources like the client, records, and tests. Common methods are observation, interviews, and health histories.
Copyright:
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HEALTH ASSESSMENT
ASSESSMENT Systematic and continuous collection, organization, validation and documentation of data The first step in the nursing process It is focus on a client’s response to a health problem Purposes of Assessment To establish a data base about a client’s physical and emotional well being, intellectual functioning, social relationships and spiritual condition To determine the client’s functional abilities and the absence and presence of dysfunction To form a therapeutic interpersonal relatioship with the client Types of Assessment Initial Comprehensive Problem-focused Ongoing Emergency Time-lapsed Data Collection Process of gathering information about a client’s health status Database – all information about a client Types of data: 1. Subjective 2. Objective Data Collection Sources of Data: 1. Primary 2. Secondary Support people Clients records Health care professionals Literature Results of laboratory and diagnostic tests Medical history and physical examination Methods of Data Collection Observation – to gather data by using the senses Interview – a planned communication or conversation with a purpose Preparation: 1. review the client’s medical records 2. conversations with other health team members 3. research of the presenting medical diagnosis Methods of Data Collection Two approaches in interview: 1. directive/structured/formal 2. nondirective/unstructured/informal Interview Questions: 1. closed-ended 2. open-ended 3. focused Methods of Data Collection Stages of Interview: 1. Introduction/Opening 2. Working/Body 3. Closure/Closing Method of Data Collection Health History - a review of the client’s functional health patterns prior to the current contact with a health care agency - used in developing plan of care and formulating nursing interventions Components of Nursing Health History Demographic information Reason for seeking health care Perception of health status Previous illness, hospitalization, and surgeries Client/Family medical history Immunization/exposure to communicable disease Allergies Components of Nursing Health History Current medications Developmental level Psychosocial history Values and beliefs Sociocultural history Activities of daily living Review of systems
