A S S E S S M E N T A N D D A TA

C O L L E C T IO N
By: Glaiza Erika O. Luces, RN
 Nursing Assessment

 Systematic and continuous collection,

organization and documentation of
data.
 A continuous process carried out during
all phases of the nursing process.
 Data collected should be relevant to a
particular problem.

 Four different types of
assessment
 Initial Assessment
 Performed within a specified time
after admission to a healthcare
agency.
 To establish a complete database and
reference.
  Problem focused assessment


 Ongoing process integrated with

nursing care
 To identify the status of a specific
problem identified in an earlier
assessment.
  Emergency assessment


 During physiologic or psychologic

crisis of the client.
 To identify life threatening problems

  Time- lapsed reassessment
 Several months after initial
assessment
 To compare the client’s present status
to baseline data previously
obtained.
 Types of data

 Subjective data
 Symptoms or covert data

 Apparent only to the person affected

 Objective data
 Signs or overt data
 Detectable by an observer

 Can be measured, or tested


  Constant data
 Information that does not change
over time
 Variable data
 Can change quickly, frequently, or
rarely
 Components of a Nursing Health
History
 Biographic Data

 Chief Complaint or Reason for Visit

 History Of Present Illness pqrst

 Family history of illness


  Past history
 Childhood illnesses
 Childhood immunizations
 Allergies
 Hospitalizations
 Medications

  Lifestyle
 Personal habits
 Diet
 Sleep and rest patterns
 ADL
 Instrumental ADL

  Social data
 Family relationships and friendships
 Ethnic affiliation
 Educational history
 Occupational history
 Economic status
 Home and neighborhood conditions
  Psychologic Data


 Major stressors
 Usual coping pattern
 Communication style

 Patterns of health care

 Sources of data

 Client - Best source of data, subjective data.

 Support people
 Family members, friends and care givers
 Important source of data if the client is young,
unconscious or confused.
 Client records
 Information documented by other healthcare
professionals

 Health care professionals –verbal
reports
 Literature -journals, reference texts,
published studies


 Data collection methods

 Observing

 Interviewing

 examining
 Observing

 To gather data using the senses

 A conscious, deliberate skill

 2 aspects:
 Noticing the data

 Selecting, organizing and interpreting

the data
 Interview

 Planned communication or conversation

with a purpose
 To get or give information

 Identify problems of mutual concern

 Evaluate change, teach, provide support

 Provide counseling or therapy


 Types of interview

 Directive interview
 Highly structured

 Controlled by the nurse

 Elicits specific information

 Nurse uses directive questions

  Nondirective interview
 Rapport-building interview

 Controlled by the client

 Rapport – understanding between two

or more people.
 Information gathering interview
 Combination of non directive and
directive interview
 Types of interview questions

 Closed questions
 Used in directive interview

 Answerable only by Yes or No

 Often begin with where, who, what, do ,

is.
 For patients who are highly stressed and
has difficulty communicating.
  Open-ended questions
 Used in non directive interview

 Invites client to explore, elaborate,

clarify thoughts or feelings.
 Useful in eliciting attitudes and mental
status
 Often begin with what and how
  Neutral question
 A question that the client can answer
without direction or pressure from the
nurse.

 Leading question
 Closed. Directive. Persuasive.
THE INTERVIEW AND SETTING
 Factors to be considered
during interview
 Time
 When the client is physically
comfortable and free of pain
 Place
 Well-lighted, well-ventilated room, free
of noise and distractions
  Seating arrangement


 Ideal seating arrangement: the nurse

and patient sit in two chairs placed at
right angles to a desk or a table or a
few feet apart with no table.
 

 Distance
 Maintain a 2 to 3 feet distance during
interview

 Language
 Avoid medical jargon
 Translators, interpreters

 Examining

 Physical examination
 Carried out systematically
 Cephalocaudal or head to toe approach
 Screening examination
 Also called review of systems
 A brief review of essential functioning of
various body parts or systems

THANK YOU!