Online Companion: Nursing Fundamentals: Caring & Clinical Decision Making

Frequently Asked Questions
Chapter 11: Assessment

What is “assessment”?

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.

What 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 spiritual condition.

What 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 emergency assessment.

What is the difference between subjective and objective assessment data?

Subjective 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.

What is the difference between primary and secondary sources of data in assessments?

A primary 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.

What 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.

What is the difference between open-ended, closed-ended, and focused questions?

Open-ended 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.

What types of data are included in a health history?

The health 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 activities.

What are the four assessment techniques used in physical examination?

The four assessment techniques used in physical examination are inspection, palpation, percussion, and auscultation.

What is “data verification,” and how is it done?

Data verification 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 findings.

What 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 Model.

What 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 patterns.

What are the four types of formats used for documentation of assessment data?

The four types of formats used for documentation of assessment data are the open-ended, checklist, combination, and specialty formats.