Nurse’s Role in

collection of additional data before making a nursing

Health
Assessment:
Collecting
and Analyzing
Data
Picture yourself in the following situations:
• You walk into Mrs. Smith’s room for the first time.
She is sitting on the edge of the bed crying and has not
changed into a hospital gown. You introduce yourself
and say, “You seem very upset.” Mrs. Smith tells you
that she is concerned about her husband being left at
home alone while she is in the hospital for colon
surgery.
judgment. For example, is Mr. Smith capable of caring
for himself? What is the physical health status of the
newborn in the trailer home? Does the community
grocery store have any carts with child safety seat belts
on them? Additional information may be gathered from
further direct observations of the client and
surroundings. In addition, you may also collect data by
talking with the client, mother, or store manager. You
conduct many informal assessments every day. For
example, when you get up in the morning, you check the
weather and determine what would be the most
appropriate clothing to wear. You assess whether you
are hungry. Do you need a light or heavy breakfast?
When will you be able to eat next? You may even assess
the physical condition of your skin.
Do you need moisturizing lotion? The assessments you
make each day determine many of your actions and
influence your comfort and success for the remainder of
the day. Likewise, the professional nursing assessments
you make on a client, family, or community determine
nursing interventions that directly or indirectly influence
the health status of your client.

• You make a follow-up visit to a new mother, Rebecca

Brown, and her 3-day-old son. You arrive at the address
provided to you and find Mrs. Brown and newborn
living in a worn-down trailer. She appears very tired.
When asked about this, she says that she has been
unable to rest because of several visitors. “I don’t mind
the attention, but I’m sorta worried that my baby is
gonna get sick because a lot of the people that have been
coming over are sick with colds.” Mrs. Brown also tells
you that she has had trouble breast-feeding. You see the
newborn in a crib and notice that his breathing is
labored. • While shopping in a grocery store, you notice
a mother with three young children. The youngest, a
boy, is in the grocery cart attempting to climb from the
cart to the checkout counter. The child does not have on
a safety belt; there is none available on the cart. The
mother is gathering her coupons together and has her
back to the boy to scold her two girls who are fighting
with each other. As a professional nurse, you will
constantly observe situations and collect information to
make nursing judgments. This occurs no matter what the
setting: hospital, clinic, home, community, or long-term
care. Each of the previous situations requires the