Comprehensive Assessment for Client's Health Database

1. Chapter 6 Assessment

2. Purpose of Assessment • Establish database concerning client’s physical, psychosocial, and emotional health • Identify: • Health-promoting behaviors • Actual or potential health problems (continued)

3. Purpose of Assessment • Data • Collection • Verification • Organization • Interpretation • Documentation

4. Types of Assessment • Comprehensive • Focused • Ongoing

5. Data Collection • Types of data: • Subjective • Objective (continued)

6. Data Collection • Sources of data • Client • Family and significant others • Other health care professionals • Medical records • Interdisciplinary activities • Diagnostic tests • Literature

7. Methods of Data Collection • Observation • Interview • Preparation • Stages • Introduction • Working • Closure • Health history • Physical examination • Laboratory and diagnostic data

8. Health History • Demographics • Reason for seeking health care • Perception of health status • Previous illnesses, hospitalizations, and surgeries • Client and family medical history (continued)

9. Health History • Immunizations and exposure to communicable diseases • Allergies • Current medications • Developmental level (continued)

10. Health History • Psychosocial history • Sociocultural history • Activities of daily living (ADLs) • Review of systems

11. Physical Examination • Purposes: • Make direct observations • Validate subjective data (continued)

12. Physical Examination • Assessment techniques: • Inspection • Palpation • Percussion • Auscultation • Laboratory and diagnostic data

13. Data Verification • Process by which data validated as complete and accurate • Examination of congruence between subjective and objective data • Findings should be compared with norms

14. Data Organization • Data clustering • Follows data collection and validation • Groups information together • Identifies strengths and weaknesses • How data clustered depends on assessment model used

15. Assessment Models • Nursing models: • Functional health patterns • Human response pattern • Theory of self-care • Roy adaptation model (continued)

16. Assessment Models • Non-nursing models: • Body systems model • Hierarchy of needs

17. Data Interpretation • Examine information • Make information meaningful • Correctly determine client problems

18. Data Documentation • Types of assessment formats: • Open-ended • Checklist • Combination • Specialty • Minimum data set (MDS)