Subjective assessment data is helpful to determine normal pattern identification and risk identification. Subjective data to obtain includes age history of chronic disease, surgeries, or traumas dietary intake activity level prescribed medications and compliance with taking medications pain and bowel and bladder functioning. Some of this information can be obtained through a chart review, but should be verified with the patient or family member for accuracy. This information must be obtained by interviewing the patient or someone accompanying the patient. Subjective assessment data is information obtained from the patient as a primary source or family members or friends as a secondary source. It is also important to consider pertinent life span or cultural considerations that impact a patient’s fluid and electrolyte status. Performing a chart review or focused health history is a good place to start collecting data, with any identified gaps or discrepancies verified during the physical assessment. AssessmentĪ thorough assessment provides valuable information about a patient’s current fluid, electrolyte, and acid-base balance, as well as risk factors for developing imbalances. This systematic approach to nursing care ensures that subtle cues or changes are not overlooked and that appropriate outcomes and interventions are implemented according to the patient’s current condition. The nursing process is used continuously when caring for individuals who have fluid, electrolyte, or acid-base imbalances, or at risk for developing them, because their condition can change rapidly.
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