Other members of the health team may also participate

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Other members of the health team may also participate (hospital: physician, PT, dietitian) - Collection of Data: o Subjective (client’s perception of his condition) o Objective (physical examination) Ongoing or Partial - Occurs after comprehensive database is established - Mini-overview of body systems and health patterns - Functions as follow-up on the health status - Problems initially detected as reassessed to determine changes (deterioration or improvement) - Brief reassessment to detect new problems - Usually done by another nurse or health professional - Can be done in hospital, community, or at home - Frequency is determined by acuity of client Focused or Problem-Oriented - Does not replace comprehensive assessment - Done after database is established (OPOC, OPNC) - Through assessment of a particular problem - Does not cover areas not related to the complaint Emergency - Very rapid assessment during life-threatening situations (choking, cardiac arrest, drowning) - Immediate assessment to provide prompt treatments - Major and only concern is to determine status of client’s life-sustaining physical functions Steps of the Health Assessment Steps in Nursing Assessment 1. Collection of Subjective Data – tend to overlap 2. Collection of Objective Data – may perform 2 or 3 steps concurrently 3. Validation of Data 4. Documentation of Data Preparing for the Assessment Client Preparation HEALTH ASSESSMENT 2020 13
- Review the client’s medical record oFamiliarize biographical data (age, sex, religion, educational level, and occupation) o Provides background of chronic diseases and clues how the present illness impacts ADLs o Awareness of past and current health status guides interactions with client o Info can also be procured from other members of the health team and significant others - Keep an open mind and avoid premature judgements (decrease accuracy of data collection) o Do not assume a 30-year old female client, an RN, knows everything about hospital routine and medical care o Nor assume a 60- year old male client with DM needs client teaching regarding diet o Do not validate information and be prepared to collect additional data - Use time to educate self about diagnosis and test performed o Unfamiliar medical diagnosis o Special blood tests (abnormal results) o Consult available resources (laboratory manual, textbook, or electronic references) - Self-awareness (reflect on own feelings) regarding first encounter with the client o Case: 22-year old with drug addiction, but you do not drink, smoke, take illegal drugs, or drinking caffeine o To avoid biases, judgement, protecting those judgements (be objective and open) o Other cases: STDs, amputation, paralysis, HIV/AIDS, abortion, sexual preferences, PWDs who are cognitively challenged - Prepare all materials needed o Equipment (stethoscope, thermometer, etc.) o Interview tools/questions/forms What is Data Collection? What is a Database?

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