ASSESSMENT

• Patient Assessment

  A systematic and comprehensive approach in which nurses collect data on a patient's physical, psychological, emotional, social, and environmental status
• Objective Data

  • Measurable and observable findings obtained through clinical examination, diagnostic tests, and observations made by healthcare providers
  • Vital signs
  • Physical assessment
  • Diagnostic / laboratory tests
• Physical assessment


  Provides crucial information about the patient's past and current medical conditions, symptoms, and relevant events
• Vital signs


  Standardized, measurable, and directly observed physiological parameters that provide factual information about the patient's health status
• Diagnostic/Laboratory Tests


  Providing objective data about the patient's physiological status. It helps detect abnormalities within the body
• Subjective Data


  • Based on the patient's self-report about their symptoms, feelings, perceptions, and experiences
  • Patient history
  • Lifestyle
  • Chief complaint
• Primary Source of Data


  Patient's own opinion, perception, and input about their condition
• Secondary Source of Data


  Input from family, friends, caregivers, and significant others
• Nursing Diagnosis


  Clinical judgment concerning a human response to health conditions/life processes, or a vulnerability to that response, by an individual, family, group, or community
• Components of a Nursing Diagnosis

  • Problem and its definition (diagnostic label)
  • Etiology (related factors)
  • Signs and Symptoms (defining characteristics or risk factors)
• PES format


  Problem and its definition (diagnostic label) + "related to" (rt) [Etiology] "as evidenced by" (a.e.b.) [Symptoms]