Nursing Process: Assessment
Category: Nursing Process
Status: Stub — content coming soon
Overview
Assessment is the first phase of the nursing process. It involves the systematic and continuous collection, organization, validation, and documentation of data about the patient’s health status.
Types of Data
| Type | Description | Examples |
|---|---|---|
| Subjective | What the patient says | ”I feel short of breath” |
| Objective | What the nurse observes/measures | RR 28, SpO₂ 91% |
| Primary | From the patient directly | Patient interview |
| Secondary | From other sources | Family, chart, labs |
Data Collection Methods
- Interview: Health history, chief complaint, OLDCARTS
- Physical Examination: Inspection, palpation, percussion, auscultation
- Review of Records: Chart, labs, imaging, prior notes
- Consultation: Other members of the healthcare team
Key Components of the Health History
- Chief complaint / reason for visit
- History of present illness (HPI)
- Past medical/surgical history
- Family history
- Social history
- Medications (including OTCs and supplements)
- Allergies
- Review of systems (ROS)
Validation
Describe the importance of validating subjective data with objective findings.
Notes
Add personal notes here.