Assessment
Collection of subjective data about the client’s perception of health of all body parts or systems, past medical history, family history, and lifestyle and health practices
What is Initial comprehensive assessment?
Collecting subjective and objective data
What is Assessment?
Review client’s record
Review client’s status with other health care team
members
What is preparing for the assessment?
introduce yourself
What is Introduction?
– Equipment
– Preparation
What is prep for physical assessment?
Thorough assessment of a particular client problem, which does not cover areas not related to the problem.
What is focused assessment?
Carrying out the plan
What is implementation?
Personal health history
Family history
Health and lifestyle practices
Review of systems
What is subjective data?
review medical record and chief complaint
What is pre-introductory phase?
• Hand Hygiene
• Gloves
• Mask, eye protection, face
shield
• Gown
What are standard precautions?
Very rapid assessment performed in life-threatening situations
What is Emergency assessment?
Determining outcome criteria and developing a
plan
What is planning?
Physical characteristics
Body functions
Appearance
Behavior
Measurements
What is objective data?
Open-ended questions
Laundry list
Rephrasing
What are types of verbal communication?
Look and observe before touching
Completely expose part being examined while draping the rest of client as appropriate
What is inspection?
Focuses primarily on the client’s physiologic
development status
What is Physical medical assessment
Assessing whether outcome criteria have
been met and revising the plan as necessary
What is evaluation?
Identify abnormal data and strengths.
Cluster the data.
Draw inferences and identify problems
What is Analysis Phase?
Summarize the information you obtained from them so far
Goals and how to achieve goals
Ask questions to ensure they understand their plan of care
Ask questions to see if they have any other concerns
What is summary and closing?
consists of using parts of the hand to touch and feel
What is palpation?
Collects holistic subjective and objective data to
determine a client’s overall level of functioning in
order to make a professional clinical judgment
What is Holistic Nursing assessment?
Analyzing subjective and objective data to
make a professional nursing judgment
What is diagnosis?
Data collection that occurs after the comprehensive database is established
What is ongoing or partial assessment?
Ask about reason for seeking care
Past medical history or family history of this issue?
Lifestyle practices
What is Working phase?
Expose the body part
Diaphragm, high-pitched sounds; bell, low-pitched sounds
Place earpieces into outer ear canal
What is auscultation?