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Online Companion: Nursing Fundamentals: Caring & Clinical Decision Making

Frequently Asked Questions

Chapter 11: Assessment

What is “assessment”?
Assessment is the first step in the nursing process. Assessment includes systematic
collection, verification, organization, interpretation, and documentation of
data for use by health care professionals.

What is the purpose of assessment?

The purpose of assessment is to establish a database about a client’s
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Contents: physical and emotional well-being, intellectual functioning, social
relationships, and spiritual condition.
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What are the types of assessments?
Instructor Resources
Students The types of assessment are (1) the comprehensive assessment ; (2) the
Videos focused assessment , concentrated upon the presenting problem of the
Sample Chapter client; (3) the ongoing assessment ; and (4), the emergency assessment .
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What is the difference between subjective and objective
assessment data?
Subjective data are information from the client’s point of view (“symptoms”),
including feelings, perceptions, and concerns obtained through interviews. Objective
data are observable and measurable data (“signs”) obtained through
observation, physical examination, and laboratory and diagnostic testing.

What is the difference between primary and secondary

sources of data in assessments?
A primary source of data is the person who is being examined. Secondary
sources include family members/significant others; other health care
professionals; the medical record; interdisciplinary conferences, rounds, and
consultations; results of diagnostic tests; relevant literature; and the nurse’s
knowledge and experience.

What are the five methods of data collection?

The five methods of data collection are observation, interview, the health
history, the physical examination, and laboratory and diagnostic testing.

What is the difference between open-ended, closed-

ended, and focused questions?
Open-ended questions are used to explore and identify problems and
concerns. Closed-ended questions are questions that can be answered with
one word. Focused questions are questions asked to obtain information
about a problem or condition that is more specific, allowing the client to
provide a response that is more than a yes or no response.

What types of data are included in a health history?

The health history includes demographic information; reason for seeking
health care; perception of health status; previous illnesses, hospitalizations,
and surgeries; the client/family medical history; immunizations/exposure to
communicable disease; allergies; current medications; developmental level;
psychosocial history; sociocultural history; activities of daily living; review of
the systems (ROS); and health promotion activities.

What are the four assessment techniques used in

physical examination?
The four assessment techniques used in physical examination are
inspection, palpation, percussion, and auscultation.

What is “data verification,” and how is it done?

Data verification is the process through which data are validated as being complete
and accurate. Data verification consists of (1) reviewing the data for
inconsistencies or omissions, (2) observing nonverbal behavior to confirm or
contradict a client’s perceptions, (3) comparing data with norms, and (4)
rechecking and confirming grossly abnormal findings.

What are some nursing assessment models used to

organize assessment data?
Examples of nursing models used to organize assessment data are Marjory
Gordon’s Human Functional Health Patterns, the North American Nursing
Diagnosis Association (NANDA) taxonomy of nursing diagnoses, Orem’s
Self-Care Theory, the Roy Adaptation Model, and the Leininger Sunrise
Model.

What are Gordon’s Eleven Health Patterns?

The 11 health patterns in Gordon’s model are the health perception-health
management, nutritional-metabolic, elimination, activity-exercise, cognitive-
perceptual, sleep-rest, self-perception–self-concept, role-relationship,
sexuality-reproductive, coping-stress-tolerance, and value-belief patterns.

What are the four types of formats used for

documentation of assessment data?
The four types of formats used for documentation of assessment data are
the open-ended, checklist, combination, and specialty formats.
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