Assessment phase of ADPIE

[Student2304]

Hi, my question is what type of information i should not collect durng the assessment phase?

[the_london_sky]

My teacher told us not to collect any "normal" values because that will not help us come up with a diagnosis.

[RNTutor, BSN, RN]

I can't think of any assessment data that I would purposely not collect on a patient! When you're doing an assessment, you're really taking in everything from the way the patient looks (any self-care deficits?) to the strength of their grip when they shake your hand, in addition to vital signs and blood tests. But depending on how you chart, you may not include all of this information in your documentation. A lot of hospitals have the policy of only charting abnormal findings, so if you don't mention it then it's considered normal.

If you're doing a care plan for school, then it is probably okay to only include abnormal findings since those are going to be the info that you use to create your nursing dx.