Nursing Process: Assessment

Front 1

Assessment

Back 1

Nursing assessment includes two steps. The first step involves the collection and verification of data from a primary source (the client) and secondary sources (e.g., family, health professionals, and medical record). The second step involves the analysis of all data as a basis for developing nursing diagnoses and an individualized plan of care for the client.

Front 2

Data

Back 2

The second step of assessment involves the analysis of all data as a basis for developing nursing diagnoses and an individualized plan of care for the client.

Front 3

Database

Back 3

The purpose of the assessment is to establish a database about the client's perceived needs, health problems, and responses to these problems. In addition, the dataq reveal related experiences, health practices, goals, values, and expectations held about the health care system.

Front 4

Positive Data

Back 4

Information that indicates a deviation from normal and suggests illness

Front 5

Negative Data

Back 5

Information which indicates there is no deviation from normal

Front 6

Limitations

Back 6

Limitations of client

Front 7

Strengths

Back 7

Strengths of client

Front 8

Observation

Back 8

Gather data by using 4 senses
sight, touch, smell, hearing

Front 9

Examination

Back 9

Also involves senses but is more sophisticated and frequently involves using an instrument
Inspection, Auscultation, Palpation, Percussion

Front 10

Focus Assessment

Back 10

In-depth assessment of a primary problem

Front 11

Primary sources of data

Back 11

Given by the client
usually most accurate - depends on mental status

Front 12

Secondary sources of data

Back 12

From significant other, health team, medical record

Front 13

Subjective Data

Back 13

subjective (symptom) - what is told, cannot be measured, observed, or validated

Front 14

Objective Data

Back 14

objective (sign) - observable, measurable

Front 15

Cues

Back 15

Information that the nurse acquires through the use of the five senses.

Front 16

Inferences

Back 16

judgements we make based on cues