Methods of Data Collection

Purposeful, structured communication in which nurse questions a patient to obtain subjective data; can be comprehensive or focused on specific area; can be formed (planned) or informal (during); use open-opended questions as much as possible

Systematic assessment of all body systems using inspection, auscultation, palpation and percussion

The conscious, deliberate use of the physical senses to gather data from the patient and environment, occurs whenever the nurse is in contact with the patient or support persons

Includes information about level of wellness, biographical information, pt. expectations, present illness, past health history, family history, enviromental history, review of systems, changes in life patterns, socio-cultural history, spiritual health, and mental and emotional reactions to illness