Monday, December 6, 2010

Head To Toe Nursing Assessment

Nursing Assessment, Assessment is the process of collecting, validating, and clustering data. It is the first and most important step in the nursing process. The assessment phase sets the tone for the rest of the process, and the rest of the process flows from it. If your assessment is off the mark, then the rest of the process will be too. Assessment identifies your patient’s strengths and limitations and is performed not just once, but continuously throughout the nursing process. After performing your initial assessment, you establish your baseline, identify nursing diagnoses, and develop a plan. Then, as you implement your plan, you also assess your patient’s response. Finally, you assess the effectiveness of your plan of care for your patient

Data can be classified as subjective and objective. Subjective data are covert and not measurable. They reflect what the patient is experiencing and include thoughts, beliefs, feelings, sensations, and perceptions. Subjective findings are referred to as symptoms. The health history is an example of subjective data. Objective data are overt and measurable. Objective data are referred to as signs. The physical examination and diagnostic studies are examples of objective data. Data sources are either primary or secondary. The patient is a primary data source. Secondary data sources are anyone or anything aside from the patient, including family members, friends, other healthcare providers, and old medical records. Both primary and secondary data can also be subjective or objective.


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