Chapter 11: Assessment
is the first step in the nursing process. Assessment includes systematic
collection, verification, organization, interpretation, and documentation
of data for use by health care professionals.
is the purpose of assessment?
The purpose of assessment
is to establish a database about a client’s physical and emotional
well-being, intellectual functioning, social relationships, and
are the types of assessments?
The types of
assessment are (1) the comprehensive assessment; (2) the
focused assessment, concentrated upon the presenting problem
of the client; (3) the ongoing assessment; and (4), the
is the difference between subjective and objective assessment data?
data are information from the client’s point of view (“symptoms”),
including feelings, perceptions, and concerns obtained through interviews.
Objective data are observable and measurable data (“signs”)
obtained through observation, physical examination, and laboratory
and diagnostic testing.
is the difference between primary and secondary sources of data
source of data is the person who is being examined. Secondary
sources include family members/significant others; other health
care professionals; the medical record; interdisciplinary conferences,
rounds, and consultations; results of diagnostic tests; relevant
literature; and the nurse’s knowledge and experience.
are the five methods of data collection?
The five methods
of data collection are observation, interview, the health history,
the physical examination, and laboratory and diagnostic testing.
is the difference between open-ended, closed-ended, and focused
questions are used to explore and identify problems and concerns.
Closed-ended questions are questions that can be answered
with one word. Focused questions are questions asked to
obtain information about a problem or condition that is more specific,
allowing the client to provide a response that is more than a yes
or no response.
types of data are included in a health history?
history includes demographic information; reason for seeking
health care; perception of health status; previous illnesses, hospitalizations,
and surgeries; the client/family medical history; immunizations/exposure
to communicable disease; allergies; current medications; developmental
level; psychosocial history; sociocultural history; activities of
daily living; review of the systems (ROS); and health promotion
are the four assessment techniques used in physical examination?
The four assessment
techniques used in physical examination are inspection, palpation,
percussion, and auscultation.
is “data verification,” and how is it done?
is the process through which data are validated as being complete
and accurate. Data verification consists of (1) reviewing the data
for inconsistencies or omissions, (2) observing nonverbal behavior
to confirm or contradict a client’s perceptions, (3) comparing
data with norms, and (4) rechecking and confirming grossly abnormal
are some nursing assessment models used to organize assessment data?
Examples of nursing
models used to organize assessment data are Marjory Gordon’s
Human Functional Health Patterns, the North American Nursing Diagnosis
Association (NANDA) taxonomy of nursing diagnoses, Orem’s
Self-Care Theory, the Roy Adaptation Model, and the Leininger Sunrise
are Gordon’s Eleven Health Patterns?
The 11 health patterns
in Gordon’s model are the health perception-health management,
nutritional-metabolic, elimination, activity-exercise, cognitive-perceptual,
sleep-rest, self-perception–self-concept, role-relationship,
sexuality-reproductive, coping-stress-tolerance, and value-belief
are the four types of formats used for documentation of assessment
The four types of formats
used for documentation of assessment data are the open-ended, checklist,
combination, and specialty formats.