The Client Database

The assessment step of the nursing process is focused on eliciting a profile of the client that allows the nurse to identify client problems or needs and corresponding nursing diagnoses, to plan care, to implement interventions, and to evaluate outcomes. This profile, or client database, supplies a sense of the client’s overall health status, providing a picture of the client’s physical, psychological, sociocultural, spiritual, cognitive, and developmental levels; economic status; functional abilities; and lifestyle. It is a combination of data gathered from the history-taking interview (a method of obtaining SUBJECTIVE information by talking with the client or significant others and listening to their responses), from the physical examination (a “hands-on” means of obtaining OBJECTIVE information), and from the results of laboratory tests and diagnostic studies. To be more specific, subjective data are what the client/significant others perceive and report, and objective data are what the nurse observes and gathers from other sources.

Assessment involves three basic activities:

• Systematically gathering data
• Organizing or clustering the data collected
• Documenting the data in a retrievable format