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First phase of the nursing process in which data are gathered to identify actual or potential health problems
Technique of listening to body sounds with a stethoscope
Practice of keeping patient information private
Pieces of data, subjective or objective, about a patient
Systematic visual examination of the patient
- Communication technique in which the nurse questions the patient in a goal-directed conversation
- Interaction and communication process for gathering data by questioning and information exchange
Observable, measurable information that can be validated or verified
Art of noticing patient cues
Use of the sense of touch to ascertain the size, shape, and configuration of underlying body structures
Examination by tapping the body surface with the fingertips and evaluating the sounds obtained
Use of the techniques of inspection, palpation, percussion, and auscultation to obtain information about the structure and function of body parts
Symptoms or covert cues that include the patient’s feelings and statements about his or her health problems
Reexamining information to check its accuracy
- Initial identification of normal function, functional status, and collection of data concerning actual or potential dysfunction
- Baseline for reference and future comparison
- Within the specified time frame after admission to a hospital, skilled nursing facility, ambulatory healthcare center, or home healthcare setting
- Status determination of a specific problem identified during previous assessment
- Ongoing process; integrated with nursing care; a few minutes to a few hours between assessments
- Comparison of patient’s current status to baseline obtained previously; detection of changes in all functional areas after an extended period of time has passed
- Several months (3, 6, or 9 mo or more) between assessments
- Identification of life-threatening situation
- Any time a physiologic, psychological, or emotional crisis occurs
The patient is the primary source of data, and the information collected from the patient is considered to be the most reliable, unless circumstances such as altered level of consciousness, severe pain, impending surgery, acute illness, or age make data collection impossible. The patient is deemed unreliable if he or she is confused or suffering from physical or mental conditions that alter thinking, judgment, or memory. In these situations, secondary sources help provide the necessary assessment information.
- Secondary sources provide data that supplement, clarify, and validate information obtained from the patient.
- Family members or significant others supplement and verify information obtained from the patient, often providing information that the patient forgets to mention or is unwilling to reveal. They may be the only source of data for children or for confused, unresponsive, or severely ill patients. Data provided by family members and significant others include a description of how the patient reacts to illness, the patient’s perceptions of changes in health status, the patient’s ability to cope with life stressors, and information about the patient’s home situation.
- Usually, the patient’s permission is obtained before information is sought from family members or significant others. All people involved must understand the confidential nature of the information they provide. The patient’s permission must also be obtained to divulge any information (e.g., diagnosis of cancer, positive HIV status, pregnancy) to family members or significant others.