Fundamentals of Nursing and Midwifery 2e

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C H A P T E R

Assessing

LEARNING OUTCOMES

After completing the chapter, the learner should be able to accomplish the following: 1. Define and describe the purpose of four types of health assessments 2. Explain the relationship between health assessment and medical assessment 3. Differentiate between objective and subjective data 4. Describe the purpose of observation, interview and physical assessment 5. Obtain a health history using effective interviewing techniques 6. Identify important sources of data 7. Plan a health assessment by identifying assessment priorities and structuring the data to be collected systematically 8. Identify common problems encountered in data collection, noting their possible cause 9. Explain when the data need to be validated and several ways in which this may be accomplished 10. Describe the importance of knowing when to report significant data and the associated documentation 11. Obtain and document complete, accurate, factual and relevant assessment data.

KEY TERMS

assessment assessment frameworks cue data database

emergency assessment focused assessment health assessment health history inference

initial assessment interview minimum data set objective data observation

physical health assessment subjective data time-lapsed assessment validation

A SSESSING IS THE FIRST PHASE in the process of planning, delivering and evaluating care. This process of assessment is explored throughout this chapter in the context of person-centred care. Health

assessment is the systematic, comprehensive and continu- ous collection, validation and communication of data about a person. These data reflect how health functioning is enhanced by health promotion or compromised by illness or

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