Sources of Data, Data Collection, and Assessment (Nursing)

by Samantha Rhea, MSN, RN

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    00:01 So, number one, guys, why do we assess? Well, there's a lot of reasons why we do this.

    00:06 First of all, we've got to see the perceived needs of the client.

    00:10 By doing this, we're going to identify health concerns from the patient, that could be things we see, or maybe the patient reports, for example.

    00:17 And then we're going to identify the primary priority problems, that's really important.

    00:24 So, this is going to give us a database of information and data to critically think through.

    00:31 And that information is going to give us a plan of care of how we move forward with treatment for a patient.

    00:37 Then we can take all that data and that plane of care.

    00:40 And again, prioritize.

    00:41 You're going to hear that a lot in nursing school.

    00:44 We got to prioritize the patient's problems, we're going to focus on our patient's needs.

    00:49 And then we're going to use our critical thinking skills to help us to get all this information, synthesize it, make sense of all this information, and use it in a purposeful way in how we treat our patient.

    01:03 Now, let's talk about that data in more detail.

    01:06 Now, when we're talking about those sources of data, we've remember, who is the primary source? Don't forget your client.

    01:13 This is where all that purposeful information comes from.

    01:17 This could be by of course, the physical examination, or head to toe assessment.

    01:21 This is going to be the best source of information.

    01:24 This could be by interviewing your client, or even just observing maybe their actions, and how they respond to treatment.

    01:31 And of course, don't forget about our objective data.

    01:34 Like our vital signs, or our diagnostic pieces.

    01:37 Like labs, x-rays, for example.

    01:41 Now, the secondary source. Again, it's a great source of data.

    01:43 We use this as a little bit more of a supporting information, such as the healthcare team, the medical records of the patient, and also any scientific literature, that's going to help back up, how we're going to treat our patient? And of course, don't forget, there's family members or significant others that know their patient really well.

    02:02 They can also be a great source of information.

    02:05 Now, key thing I want to tell you.

    02:08 Family dynamics, significant others can be, there can be some different dynamics going on there.

    02:15 So make sure you check with your client first, to make sure you can gather information from the family or the significant other.

    02:25 Now, let's talk about data.

    02:27 So this is really important as a nursing student, because there's a difference between the type of data that we use.

    02:34 we call it subjective and objective data.

    02:37 So when you're talking about subjective data, this is an important point as a nursing student to distinguish between the two.

    02:45 So subjective would be, what you're told? Versus objective, meaning, what you can actually see or validate? Here's a great example I like to use personally, such as, "Oh, my patient may tell me, I'm nauseated." Well, it's really kind of hard to tell if I look at someone, just me as the nurse to really see that they're nauseated.

    03:06 I can see objectively though, if the patient vomits, right? So that's a great example of subjective versus objective data.

    03:15 So here's a classic example.

    03:17 Pain, for example.

    03:19 Such as, my patient may tell me, "I'm having very bad pain in my leg." In a lot of times, again, subjective data is what the patient's going to tell you.

    03:29 Such as, again, "I'm having very bad pain in my leg." Well, the objective data would be, if the patient goes, and gets up, and walks to the bathroom and you see them grimacing, or limping, when they're walking, I can tangibly and objectively see that as a nurse.

    03:45 And that's what I would document as my objective data.

    03:49 Here's another example, such as, "My client has a fever." So I can't see that my patient has a fever.

    03:57 But objectively, I can take a temperature and the client's temperature is 101.0 degrees Fahrenheit.

    04:05 I can tangibly and objectively see that my patient is running a fever.

    04:10 So just know, again, as a nursing student, it's important that you distinguish and as a nurse subjective versus objective data, because this is going to be important for our documentation.

    04:23 Now, let's talk about that process and that data of assessment.

    04:27 So first of all, if you remember with assessment for maybe our primary or secondary source, we're going to collect all that data.

    04:35 There's a lot of it.

    04:37 So then, this is again, where that critical thinking comes in that we've got a cluster all that information.

    04:44 And we'll start with experience as a nurse, identifying similarities between certain disease processes and certain patient complaints, for example.

    04:55 Then we're going to start connecting more information to form a complete clinical picture.

    05:00 And again, guys, just know as a new nurse, this takes a little time.

    05:05 But with experience, this gets much better.

    05:08 So sometimes we're starting to collect more information such as laboratory results, for example, diagnostic reports.

    05:16 Maybe a physician know to pull in with what we assess, to form a better clinical picture for us as a nurse.

    05:24 And lastly, with assessment, be sure you have supporting cues before making an inference.

    05:30 What do I mean by this? So when we're assessing our patient, we need to not just make a judgement based on no information, right? We need to have supporting assessment information, supporting information from the patient, maybe client complaints, before we make a judgement about what the client needs.

    05:50 Now, let's talk about some assessment approaches on how we gather information.

    05:55 There's three very common types we'll talk through.

    05:58 So the first one is the health history.

    06:01 This is really important because this gathers information.

    06:04 And this lets us really understand the patient's current health problems such as, maybe they have a past medical history of diabetes, or they've had surgery recently.

    06:14 This is all important for us to know, as a nurse, when we're taking care of them.

    06:20 And of course, the head to toe physical assessment.

    06:22 Guys, we get so much information from this.

    06:26 This gives us a really baseline idea of what our patient condition is.

    06:30 It also helps us recognize any abnormalities that we may need to treat or report to our physician.

    06:37 And don't forget focused assessment.

    06:40 So this is looking closely at a particular area of concern.

    06:44 So maybe your patient's complaining of gastrointestinal upset.

    06:49 We're going to do more of a focused assessment, and ask more probing questions due to our patient complaint here.

    06:57 Now, let's talk about different methods of information collection.

    07:02 And first of all, we're going to start of course, with a client centered interview.

    07:06 So this is really important, because we're going to have an organized conversation with the client.

    07:11 This is typically in the form of a health history of a client, for example.

    07:15 Or also known as the admission history assessment.

    07:19 So when we start, we're going to set the stage.

    07:22 We're going to go ahead, have our information ready to ask our clients.

    07:26 We're going to greet them, let them know who we are, and what we're doing.

    07:31 It's also really important to consider the environment.

    07:34 And this is a lot of times things that we don't consider as a nurse.

    07:37 So it's important that, if I go in to ask a patient about a lot of personal questions about their health history, if we can minimize distractions, that's going to help a lot.

    07:48 Also, it's a good idea to sit and organize the agenda about how you're going to gather the information, and also the clients concerns.

    07:57 Now, we can go ahead, and collect the assessment, or that nursing health history.

    08:01 And again, make sure that we assure client confidentiality.

    08:05 Sometimes clients are a little bit concerned about telling us really intimate details for the fact that they're worried that that information is going to go outside in just you and the patient.

    08:16 But this is important to assure confidentiality with your patient.

    08:21 Now, once we've gathered our information successfully, we can terminate the interview.

    08:27 Now, let's talk a little bit more about when you are doing that client interview.

    08:31 How are you going to interview them? Let's talk about a few tips about six that are good things to remember, when you're interviewing a client.

    08:39 One of those are open-ended questions.

    08:43 You'd be surprised when you sit down with a patient and just say, Hey, here's an example.

    08:48 "How are you feeling?" Or you can get a lot of information by just setting, asking a simple open-ended question and then letting the patient talk.

    08:58 It's also important to ask clarifying questions, such as, "Did I hear you say, etc.?" So sometimes what that does is let the patient know that you're listening to them.

    09:09 And also helps affirm the information that you're getting.

    09:13 And don't forget to validate the information.

    09:16 The reason why this is important, accurate information is critical on making a plan of care for a patient.

    09:24 So here's kind of a small example of that is maybe you get a report that the patient's been reporting pain in their leg.

    09:30 So when I go to see my patient, I'm going to validate that information.

    09:35 I'm going to check with my patient say, "Hey, I heard that you were having pain.

    09:39 Can you tell me where? Can you rate that from a 0 to 10 scale? Can you tell me about that pain?" So we need to make sure that that information we receive is accurate.

    09:50 And again, we've talked about this briefly.

    09:53 It's important, especially with those open-ended questions like we were talking about.

    09:58 Try not to interrupt your patient too many times.

    10:01 It's important that when the patient's talking, try to avoid interruptions.

    10:05 And of course, there are different cultural, behavioral differences that we need to be respectful of.

    10:11 So, if I go into my client's room, some clients may be really uncomfortable with eye-to-eye contact.

    10:18 Now, if I'm eye-to-eye contact during the whole interview that may intimidate your client.

    10:23 So you need to be aware of these cultural or behavioral differences.

    10:28 And lastly, don't forget about that data we talked about.

    10:31 Differentiate between subjective, which is usually what the patient tells you and objective information because again, this is going to be important on how we treat, and also how we document.

    About the Lecture

    The lecture Sources of Data, Data Collection, and Assessment (Nursing) by Samantha Rhea, MSN, RN is from the course Nursing Process – Assessment, Diagnosis, Planning, Interventions, and Evaluation.

    Included Quiz Questions

    1. To identify the client’s perceived needs
    2. To identify health concerns
    3. To identify primary problems
    4. To identify a medical diagnosis
    1. “I have collected the client’s vital signs for the last two days.”
    2. “I have a copy of the client’s surgical report from two years ago.”
    3. “I interviewed the client’s family doctor.”
    4. “I looked up a study on epilepsy, as that is one of the client’s diagnoses.”
    1. The client is clutching their abdomen and grimacing.
    2. The client’s abdominal incision is dehiscing.
    3. The client has started to vomit.
    4. The client describes their pain as ‘ten out of ten’.
    5. The client’s mother says the client has been complaining of abdominal pain for two hours.
    1. Data collection
    2. Cluster information and identify similarities
    3. Collect more information to form a complete clinical picture
    4. Ensure there is supporting information before making an inference
    5. Make several inferences and then collect information to support them
    1. “Are you having pain? Yes or no?”
    2. “Can you tell me how you’re feeling today?”
    3. “Your father told me you’re having stomach pain, can you tell me about it?”
    4. “You said you’ve had this pain for about 30 minutes?”

    Author of lecture Sources of Data, Data Collection, and Assessment (Nursing)

     Samantha Rhea, MSN, RN

    Samantha Rhea, MSN, RN

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