Assessment Essentials
This first step of the nursing process involves systematically collecting information about a patient’s health status.
Assessment or data collection
Asking the patient questions about symptoms, health history, habits, and concerns is this method of data collection.
The interview
Information that the patient describes, such as nausea, dizziness, fatigue, or pain, is classified as this type of data.
Subjective data
Because this person usually provides the most direct information about symptoms, concerns, and health practices, this person is the primary source of data.
The patient
A broad statement describing the desired change in a patient’s condition, behavior, or level of functioning is called this.
Patient goal
The primary purpose of collecting assessment data is to create this organized collection of information about the patient.
The patient database
Using the senses to notice the patient’s appearance, behavior, movements, breathing pattern, and surroundings is this method.
Observation
Measurable or observable information, such as a temperature of 101°F, a rash, or a blood pressure of 150/90 mmHg, is this type of data.
Objective data
Family members, caregivers, health records, laboratory reports, diagnostic results, and other healthcare professionals are classified as these sources.
Secondary sources of data
Specific, observable, and measurable indicators used to determine whether a patient goal has been reached are called these.
Outcome criteria or expected outcomes
Assessment data help the nurse identify patient problems, establish priorities, plan care, and create these standards for measuring progress.
Outcome criteria
Inspection, palpation, percussion, and auscultation are techniques used during this data-gathering method.
The physical examination
“My incision burns whenever I move” is an example of this type of assessment information.
Subjective data
After collecting data, the nurse organizes related findings into groups through this process.
Clustering data or identifying patterns
Specific, measurable, attainable, relevant, and time-limited are the qualities represented by this goal-writing acronym.
An assessment that collects broad information about the patient’s physical, psychological, social, cultural, and spiritual health is called this.
Comprehensive assessment
These are the three basic methods used to gather a patient database.
Interviewing, observation and physical exam
Guarding the abdomen, facial grimacing, and a heart rate of 110 beats per minute are examples of this type of information.
Objective data
Clue: Shortness of breath, low oxygen saturation, rapid respirations, and abnormal breath sounds may be correlated with this priority problem.
Impaired oxygenation
“The patient will report pain at 3 or lower on a 0-to-10 scale within one hour of receiving pain medication” is an example of this.
A measurable, time-limited outcome criterion
An assessment that concentrates on a specific symptom, concern, body system, or previously identified problem is called this.
A focused assessment
The opening, body, and closing are the three basic stages of this assessment activity.
The patient interview
The nurse compares information from different sources and checks questionable findings through this process.
Data validation
Pain rated 8 out of 10, guarding, facial grimacing, and reluctance to move may support this problem statement.
Acute pain
A properly written patient outcome should include the patient, an observable behavior or response, the conditions when appropriate, this measurement standard, and a target time.
A performance criterion