indonesiannursing.com

The nurse must possess strong cognitive, interpersonal, and technical skills in order to elicit appropriate information and make relevant observations during the data collection process. This process often begins prior to initial contact between the nurse and the client, primarily through the nurse’s review of biographical data and medical records. Upon meeting the client, the nurse continues data collection through interview, observation, and examination. A variety of sources and methods are used in compiling a comprehensive database.
Types of Data
Client data include information that the client communicates concerning perceptions of his or her own health status, as well as specific observations made by the nurse. These two types of information are referred to as subjective and objective data. Subjective data are data from the client’s point of view and include feelings, perceptions, and concerns. (continue reading…)

The type and scope of information needed for assessment are usually determined by the health care setting and needs of the client. Three types of assessment are comprehensive, focused, and ongoing. Although a comprehensive assessment is most desirable in initially determining a client’s need for nursing care, time limitations or special circumstances may dictate the need for abbreviated data collection, as represented by the focused assessment. The assessment database can then be expanded after the initial focused assessment, and data should be updated through the ongoing assessment process.
Comprehensive Assessment
A comprehensive assessment is usually completed upon admission to a health care agency and includes a complete health history to determine current needs of the client. This database provides a baseline against which changes in the client’s health status can be measured and should include assessment of physical and psychosocial aspects of the client’s health, the client’s perception of health, the presence of health risk factors, and the client’s coping patterns. (continue reading…)

The purpose of assessment is to establish a database concerning a client’s physical, psychosocial, and emotional health in order to identify health promoting behaviors as well as actual and/or potential health problems. The American Nurses Association (ANA), in its Standards of Clinical Nursing Practice (1998), supports the use of the nursing process and outlines the essential components of assessment in this process. Through assessment, the nurse determines the client’s functional abilities and the absence or presence of dysfunction. The client’s normal routine for activities of daily living and lifestyle patterns are also assessed. Identification of the client’s strengths provides the nurse and other members of the treatment team information about the skills, abilities, and behaviors the client has available to promote the treatment and recovery process. Some examples of client strengths are family support, intelligence, spiritual beliefs, and coping skills (how previous problems have been solved). The assessment phase also offers an opportunity for the nurse to form a therapeutic interpersonal relationship with the client. During assessment, the client is provided an opportunity to discuss health care concerns and goals with the nurse.