N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide risk that has been identified. This will typically be a more in-depth look at just one system or one patient need. • The ongoing assessment is the one used most often by the nurse, since it is the systematic follow-up to issues or problems identified in a comprehensive or focused assessment. Every contact with a patient will involve aspects of the ongoing assessment. The data obtained from these contacts will be used to update the information about the patient and the plan of care with the patient. Types of Assessment Data The nurse collects many types of data during the assessment process: • Data can be classified by the source of the data: o Primary source data is the data that comes directly from the patient through interviews or physical assessment. o Secondary source data is the data that comes from any other source other than thepatient. This might be old medical records, other providers, or friends and family of the patient. • Data can be classified as subjective or objective: o Subjective data are sometimes called symptoms. Symptoms are generally elicited from the patient during the interview process. Symptoms can only be describedby the patient and may or may not be quantifiable. Subjective data will include the patient’s perceptions of his health, sensations he is feeling, thoughts, beliefs, concerns, and attitudes. Subjective data might include things like reported itching, bloated feeling, and worry about health. Symptoms will prompt the astute nurse to look for the objective data to support the subjective reports. o Objective data are called signs. Signs are observable and measurable data that can be obtained through physical assessment or diagnostic testing. Signs can be seen, felt, smelled, or heard by the nurse who is doing the assessment. Signs can be used to validate the symptoms reported by the patient. For example, the nurse may see a rash (the sign) that supports the patient’s report of itching (the symptom). Subjective Data Objective Data Primary Source Data “My back is itching.” Nurse sees a fine rash on the patient’s back. Secondary Source Data “My mother is confused.” “My mother could not remember my father’s name.” Components of the Assessment During the assessment, the nurse must ensure that the patient is comfortable and that the patient’s privacy and modesty are protected. The assessment should be conducted in a quiet, private room. Any of the assessment types may have one or more of these components in the assessment: • The interview: Effective interviewing involves guiding the patient through the interviewwhile also encouraging the patient to provide as much information as possible. To do this, the nurse

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