NURSING 1I02 Chapter Notes - Chapter week 4: Medical Record, Concept Map, Health Promotion
26 Jan 2018
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Assessment: assessment is the collection of data used to determine a client"s current and past health status and functional status and to determine the client"s present and past coping patterns, nursing assessment consists of two steps: Data collection: cue is information that we obtain from the use of senses (crying implies fear/sadness, inference is our judgement or interpretation of those cues; you have to document cues before you can make an inference. Types of data: two primary sources of data: subjective and objective, subjective data are your clients" verbal descriptions of their health problems. Only clients provide subjective data; include feelings, perceptions, and self-report of symptoms: objective data are observations or measurements of a client"s health status. Inspection of the condition of a wound, a description of an observed behaviour, and the measurement of blood pressure are examples of objective data.
