 Hi and welcome to Nursing School Explained. This video is the first video in the series about the different steps of the nursing process and the first step is always assessment. So let's take a look at this. In the assessment phase, we gather information about the patient. Now we have to distinguish between subjective and objective data. Subjective data is anything that the patient tells us about. So basically it's their subjective information, anything that they share with us. And of course we're going to have to probe and ask close as well as open-ended questions to get the answers that we need to determine what we need to do for this patient in their care. Now the objective data is basically all the observations that we do. And there are several things that are included in this objective data. So it first starts with the chief complaint or sometimes this has a little bit of a negative connotation. So some people call it the reason for seeking care. And then we go into the history of the present illness. So what happened that brought the patient to the hospital that contributed to the reason for seeking care? Number three would be a review of systems where we systematically approach all the different body systems to determine how might other symptoms for other body parts be related to the patient's reason for seeking care. And then we have to look into their past medical history, past surgical history, allergies, current medications, family history, as well as psychosocial history. Again all this is objective data that we'll ask the patient about. And then we have our physical assessment which is one of the most important parts of gathering data in the assessment phase. And that of course includes vital signs. And for the physical assessment we always approach the patient in a methodical head to toe way. Then we don't miss anything. And so some students get nervous because they might forget to do one of the other things. Now the order of operation doesn't really matter. So for example whether you listen to the patient's anterior or posterior lungs first doesn't really matter. If you listen to the heart first and the lung second vice versa, it doesn't matter as long as you cover that. And if you always approach the patient in the same systematic way you will not forget to assess an important part and miss gathering some of this important data we're trying to accomplish here. For physical assessment we also want to make sure that we have a focused assessment so we don't necessarily assess all the different very intricate details of the patient every single time we assess them. But we make it focused referring back to their reason for seeking care and the history of their present illness. So for example if they're therefore a respiratory problem we're going to focus on the respiratory system. But that also means we have to assess their circulatory status, their orientation because oxygenation has a lot to do with those and those signs and symptoms might be apparent if the patient is not doing well with their oxygenation. And then the other important objective data are labs so any kind of lab values that we can gather as well as diagnostic tests such as chest x-ray, MRIs, CAT scans, echocardiograms and so forth. Now if we look at a specific example here, so if we say the patient's chief complained the reason for seeking care is shortness of breath. So they're telling us I am short of breath and that's why I'm here. Okay history of the present illness, how long have you been short of breath? When did it start? Do you have any other associated symptoms? Review of systems such as chest pain referring back to the cardiovascular system? Do you have any palpitations? Do you have any headaches? Do you feel dizzy? Then of course we're going to assess the patient's mental status to see are they refusing? Well, do they get enough oxygen to the brain as well as of course assess their lung sounds, their respiratory rate and all these assessments as well as for circulation we're going to listen to the heart sounds, measure the peripheral pulses, check their skin color, their cap refill, all these things that we can assess to see are they oxygenating while not at their complaining of shortness of breath. And then for example for past medical history and surgical history they might tell us oh yeah I have a history of hypertension, congestive heart failure, I smoke and I'm married so those are important things to note here. Now what's also important here is that we also only ask for pertinent information and sometimes students have a little bit of a difficult time to find out what's pertinent. So in this example of the shortness of breath this data here with the history of hypertension congestive heart failure being a smoke or being married is important. What's not important is that the patient had an appendectomy at the age of six that does not really have any relationship to their shortness of breath. That might be noted somewhere in the past surgical history but really it is not pertinent information it does not somehow relate back to their shortness of breath. And then we're going to ask them about their medications so maybe they're telling us they're taking lasix and the synopril so maybe your your life option would be going off saying okay I know the patient is taking these two medications I know they work on the patient's fluid volume status they work on their kidneys they have something to do with potassium so now let me see if I can look at their labs. So CDC would tell us about the hemoglobin and hematocrit. So if they have a low H and H they might feel short of breath because now they only have half the tank full so that means they have decreased blood cells available to perform the oxygen oxygen carrying into the different cells and so now of course they want to feel short of breath. We're going to assess the metabolic panel to look at their electrolytes and also their kidney function because we know with CHF they could be in fluid volume overload and affecting their kidney function. We might want to look into a BNP to assess their cardiovascular status and the status of their congestive heart failure over a D-dimer if you were worried about clotting. And then other diagnostic tests that might be a chest x-ray and EKG if they're complaining of chest pain palpitations and especially given the history of congestive heart failure and then maybe an echocardiogram to look at that hard in a little bit more detail. Now with this here is a little bit too complicated for you depending on where you are in your in your nursing career don't worry about it you start making these connections as you move on and through your nursing program but the important part here is that we need to look at all these details and refer it back to the patient's chief complaint the reason for seeking care but to really take all this into consideration in the assessment phase because if we don't gather all this data during the assessment phase we might not think to check a BNP or a D-dimer or an EKG and then we're going to miss an important part of the assessment data and then we're going to miss identifying a problem that the patient might have and they will not get better. Now once we've accomplished gathering all our data here by questioning the patient about all these things and performing our physical assessment then we can move on into phase two of the nursing process which is the problem identification prior to realization of the problems also known as nursing diagnosis. Now depending on where you are in your program what they prefer to use you might still be using nursing diagnosis although it's a little bit outdated but what you call it doesn't really matter what matters is that now you've gathered all this data and you need to prioritize what you're going to focus on with your patient to get them well. Now watch the next video on where I go into the details into the problem identification and prior to realization so you can learn a little bit more about that. Thanks for watching Nursing School Explained.