V Processof collecting data to identify

actual & potential health problems and

strengths of the client.

V The systematic and continuous

Date Collection
Verification
Organization
Interpretation
Documentation

of DATA (information).
V comprehensive information you gather on
initial contact ©ith the person to assess all
aspects of health status.

V Initial data collected

V ´FOUNDATIONµ of the client database

V !ystematic, ongoing, and continuous
V Provides a sense of the client·s overall status
V Gathered during a/an:
hysical Examination
ántervie©
Ôevie© of Diagnostic studies
V Information is analyzed and validated
V Facts are clustered into groups of
information
V Data are accessible to other health care
team members.
V The process of gathering information about a
client·s status.

V Reflects a client·s changing health status.

V Begins
©hen the client enters the health care
system.

V Must be systematic and continuous.

V Continuesas long as there is a need for

health care.
V!
á

Also referred to as !

! (covert data)

Comes from the person affected and can be
described or verified only by that person.
!tatement, feelings, perceptions, or concerns
communicated/verbalized by a client.
u Examples:
V ITCHING
V PAIN
V FEAR
V `
á

Also referred to as !! (overt data)

Detectable by an observer or can be measured or tested
against an accepted standard.
Can be perceived using the 5 senses.

u Examples:
V TEMPERATURE
V PUL!E RATE
V RE!PIRATORY RATE
V BLOOD PRE!!URE
V !UBJECTIVE V OBJECTIVE
´I feel ©eak all over ©hen I -BP: 90/50, HR: 104bpm,
exert myself.µ skin pale and diaphoretic.

Client states he has -vomited 100ml green-tinged

cramping pain in his fluid
abdomen. !tates, ´I feel
sick to my stomach.µ -abdomen firm and slightly
distended
-active bo©el sounds
auscultated in all four
quadrants
´I·m short of breath,µ as -Crackles heard upon
verbalized by the client. auscultation
-RR: 28bpm
V ÔáÔ r the client himself.

Ô
b
t ourc
of data i t
cli
nt, unl
 t

cli
nt i too ill, young, or confu
d to
communicat
cl
arly.

V !`
Ô r all information that can be

obtained from others ©ho kno© the client
and from records or documents that are
related to the client·s condition.
!
! 

‰ Ú

Ú
 
‰      Ú

‰ 
 
‰   

‰  Ú  

V Assessment Tools
Based on nursing models considered
À


V !ome tools are based on problems

commonly encountered on a particular
unit.
(Ex: Pediatric and Geriatri data collection
tools)
 ´P~I~Oµ
VP - hysical Examination

VI rntervie©

VO rbservation
 Gathering data by using the senses.
A conscious and deliberate skill that is
developed through effort and ©ith an
organized approach.
!kill of ©atching thoughtfully and
deliberately.
Is used to detect the client·s overall
appearance and behavior.
· Includes:
å physical and emotional responses
å Body language/posture
‡Moods
‡Interaction
‡!ocial and cultural characteristics
V ´c
ntral to nuring practic


V It is the fundamental element

in establishing restorative
nurse-client relationship

V COMMUNICATION
Ability to appropriately
understand, transmit and
receive thoughts, feelings, and
facts.
Verbal and non-verbal
communication.
V Isa planned communication or a conversation ©ith a
purpose (to collect information).

V Communication exchange bet©een a cli
nt and a

nur
.

V T©o approaches: uir
ctiv
and Non-dir
ctiv

V Types of communication: Ô
rap
utic and ocial

V Highlystructures and elicits specific
information.

V Nurses controls the intervie©.

V The nurse establishes the purpose

V Is
used to gather and to give information
©hen time is limited.
V Also kno©n as ´rapport building intervie©.µ

V Thenurse allo©s the client to control the

purpose, subject matter, and pacing.
V Promotes understanding
V Helps establish a constructive relationship
bet©een the nurse and the client.
V Involves establishing a caring and empathic
relationship ©ith the client.
V For the purpose of data collection
V Purposeful
V goal-directed
V focused on the client
V planned
V Casual conversation

V !pontaneous

V No planned agenda
V Revie© medical records

V Revie©current admission documentation of

past and present client care

V Researching present and past medical

diagnoses
V Language differences
V !ociocultural differences
V Gender
V Health status
V Developmental level
V Kno©ledge differences
V Emotional distance
V Emotions
V Daydreaming
V Intervie© in a private setting
V Introduce yourself
V Use appropriate title ©hen addressing the
client
V !tate the purpose of the intervie©
V Maintain eye contact
V Do not rush through the data collection
tool
V Therapeutic communication techniques

Active lit
ning

Conveying acc
ptanc

Being att
ntiv

!itting at
y
l
v
l ©ith the client

Establish
y
-to-
y
contact

1. Introduction phase

2. Working phase

3. Closure phase
á

á 

V Can be the most important part of the
intervie©

V Goals are stated

V Purpose and use of collected data should be

discussed

V PURPO!E: Establish rapport

Orient the client

V !tep 1 r Establish RAPPORT
Nur
 Hello, Mr. Dimagiba, I·m Ms. Batombakal,
I·m a nursing student, and I·ll be assisting ©ith
your care here today.
Cli
nt Are you a student from Upang?
Nur
 Yes, I·m in my 3rd year. Are you familiar
©ith the campus?
Cli
nt O y
 I·m an avid ba
tball fan. My
n
p
 graduat
d in 2004, and i oft
n att
nd
ba
tball gam
 it im.
Nur
 That·s great! !ounds like fun.
Cli
nt Yes, I enjoy it very much.
V !tep 2 r ORIENTATION
Nur
 May I sit do©n ©ith you here for about 10 minutes to
talk about ho© I can help you ©hile you·re here?
Cli
nt All right. What do you ©ant to kno©?
Nur
 Well, to plan your care after your operation, I·d like
to get some information about your usual daily activities
and ©hat you expect here in the hospital. I·ll take notes
©hile ©e talk to get the important points and have them
available to the other staff ©ho ©ill also look after you.
Cli
nt OK. That·s all right ©ith me.
Nur
 If there is anything you don·t ©ant to talk about,
please feel free to say so. Everything you tell me ©ill be
confidential and only be shared ©ith others ©ho have the
legal right to kno© it.
Cli
nt !ure, that ©ill be fine.
üá 

V Focused on the details of data collection.

V Collect comprehensive data.

V Client communicates ©hat he/she feels,

thinks, kno©s, perceives in response to
questions from the nurse.
1. Ask relevant questions

2. Use correct t
rminology

3. Use Open-ended questions and comments,

reflection, summarize, restate.

4. Use an organized, systematic assessment

tool.
1. Open-ended question

2. Close questions
V Invites the client to explore, elaborate,
clarify, or illustrate their thoughts or
feelings.
V !tated in a manner that encourages the
client to elaborate about a particular
concern or problem.
V May begin ©ith ´Whatµ or ´Ho©µ
Ex: ´Ho© have you been feeling lately?µ
´What brought you to the hospital?µ
´I·d like to hear more about that.µ
´What is you opinion?µ
V Are restrictive, and generally requires only ´y
 or
´no or factual ans©ers giving specific information.
V Appropriate in ¦M¦
¦NCY or LIF¦-Ô ¦Ô¦NIN

ituation.
V often begin ©ith ´©hen,µ ´©here,µ ´©ho,µ ´©hat,µ
´do (did, does),µ or ´is (are, ©as).µ
V Examples: ´What medications did you take?µ
´Are you having pain no©?µ
´Ho© old are you?µ
´When did you fall asleep?µ
è 

 

C ild ´Ug  Ô at· poo poo
Nur
 ´Ô
m
dicin
tat
pr
tty bad, u 

Cli
nt ´I couldn·t manag
to
at any dinn
r lat nig t³not

v
n d

rt.
Nur
 ´You ad difficulty
ating y
t
rday 
2. Clarifying
¦ ´I·m not ur
t at I und
rtand  at you·r
aying
´uo you m
an... 
Cli
nt ´I vomit
d t i morning.
Nur
 ´Wa t at aft
r br
afat 
3. Focusing
Ex: ´L
t· loo at t i mor
cl
arly.
´ L
t· r
turn to t
lat point you mad
and tal mor

about t at.

CLI¦NÔ ´My if
ay 
ill loo aft
r m
, but I don·t
t in 
can,  at it t
c ildr
n to ta
car
of, and
t
y ar
alay aft
r
r about om
t ing³clot
,
om
or,  at· for dinn
r t at nig t.
NU ¦ ´ound li
you ar
orri
d about o 
ll 

can manag
.

4. !ummarizing
Ex: ´L
t· r
vi
  at 
av
jut cov
r
d in t i
int
rvi
.
´uuring t
pat alf our 
av
tal
d about...
1. Inattentive listening

2. Using unfamiliar medical terminology

3. Asking unrelated personal questions

4. False reassurance

5. Inappropriate socializing boarders

6. Passive responses

7. Aggressive responses
O
 
V Nurse
terminates the intervie© ©hen the
needed information has been obtained.

V !ummarize overall information.

V Plan for the next meeting, if there is to be

one.
V Isa systematic data collection method that
uses observation to detect health problems.

V PURPO!E:- collect data regarding client·s

present health status.
- to establish a baseline physical
assessment.
 á



VI rN!PECTION

VA r U ! C U LTATI O N

VP rALPATI O N

VP rERCU!!ION
V Isa systematic process of observation that
includes ´2IION.

V U
LI
Ô

V Maintain P I2CY

V ¦PLIN t
inp
ction t
c niqu

V Techniquefor listening sounds ©ithin the
body, usually ©ith !TETHO!COPE.

V Most often auscultated: lungs, heart,

abdomen, and blood vessels.
V Involvesthe use of TOUCH or PRE!!ING on the
external surface of the body ©ith the fingers.
V Examples of its U!E!:
TOUCH: to detect mass or skin conditions.
PRE!!URE: to feel the quality and rate of an
arterial pulsation.
DEEP PALPATION:- for assessment of deep,
internal organ anomalies
- to determine if client is
experiencing an abnormal response to
pain.
V Isthe technique involving direct or indirect
tapping of a specific body surface to glean
information about internal organs beneath
the body surface.

V May use fingertips, fist or percussion hammer

to elicit various tone indicating:
‡ Presence or absence of fluid or air
‡ Masses
‡ Consolidation
‡ Tenderness
‡ Normal or abnormal reflexes
V BODY !Y!TEM! APPROACH
M Investigates each system individually

V CEPHALOCAUDAL
u Head-to-toe approach; begins the
examination at the head;
u progresses to neck, thorax, abdomen and
extremities;
u Ends at toes.
V To ensure ´CCU CY and ´FCÔULIÔY

V VERIFIED r confirmed or proved

V VALIDATED r determined to be fact

- act of ´double-checkingµ
V INTERPRET r determining the meaning and
significance.
V ANALYZE r processing information to reach a
conclusion.
V Int
rpr
ting and analyzing ² help identify missing
information or inconsistencies
V DATA CLU!TERING r is the process of orginizing
subjective and objective data into groups or related
cues.
V Isthe process of preparing a record that
reflects the assessment data and describes
the client·s present health status.
V A form of communication.
V Ex: t
nur
r
cord t
cli
nt inta

(obj
ctiv
data) a ´coff

240ml,
juic

20ml,

gg, and
lic
of toat,
rat
r t an a ´good app
tit
or ´normal
app
tit
 may av
diff
r
nt m
aning for
diff
r
nt p
opl
.
Ô


  
ÔÔÔ