STEPS OF HEALTH ASSESSMENT

Data Collection

- Process of gathering information about a client’s health status.

- Both systematic and continuous to prevent the omission of significant data
- Allows a nurse, client and health care team to identify health-related problems or risk factors that could
cause changes in a client’s health status.

A. Collecting subjective data

 Symptoms or covert data.
 Apparent only to the person affected and can be described or verified only by that person.
 Itching, pain and feelings of worry.
 Include the client’s sensation, feelings, values, beliefs, attitudes and perception of personal health
status and life situation.

B. Collecting Objective data

 Signs or overt data.
 Detectable by an observer or can be measured or tested against an accepted standard.
 Can be seen, heard, felt, or smelled.
 Obtained by observation or physical examination.

C. Validating assessment data

Validation

- Verifrying data collected to confirm that it is accurate and factual

Guidelines

 Compare subjective and objective data to verify the client’s statements with your observations.
 Clarify any ambiguous or vague statements.
 Be sure your data consist of cues and not inferences.
 Double-check data that are extremely abnormal.
 Determine the presence of factors that may interfere with accurate measurement.
 Use references to explain phenomena

D. Documentation data

Documentation
 Provides a foundation of care
 Helps to identify health problems, formulate nursing diagnoses and plan immediate and ongoing
interventions
Guidelines

 Write entries objectively, avoiding inferences or medical diagnosis

 Use quotations if it is a patient statement
 Support objective data with observations
 Record the client’s understanding and perception of problems
 Avoid recording the word “normal”, use descriptive words.