Health assessment notes (1)

Nursing Process

A systematic approach to providing nursing care, consisting of five phases:assessment, diagnosis, planning, implementation, and evaluation.

Objective Data

Information obtained through observation, physical examination, and review of the patient's health record.

Ongoing or Partial Assessment

Data collection after the initial comprehensive assessment, focusing on reassessing any problems detected in the client's body system.

Focused or Problem-Oriented Assessment

A thorough assessment of a particular client problem, excluding areas not related to the problem.

Emergency Assessment

A rapid assessment performed in life-threatening situations, requiring an immediate diagnosis for prompt treatment.

Collection of Subjective Data

The first step of health assessment, involving the gathering of information about the patient's biographical information, physical symptoms, past health history, family history, and health and lifestyle practices.

Collection of Objective Data

The second step of health assessment, involving the observation of physical characteristics, body functions, appearance, behavior, measurements, and laboratory results.

Validation of Data

The process of confirming or verifying that the subjective and objective data gathered are reliable, accurate, and complete.

Documentation of Data

The process of recording the gathered data to provide a database for the healthcare team, helping to identify health problems, formulate nursing diagnoses, and plan care.

Critical Thinking

Purposeful mental activity that guides beliefs and actions, involving problem-solving, decision-making, self-directed, self-disciplined, self-monitored, and self-corrective thinking.

Universal Intellectual Standards for Critical Thinking

Standards that must be applied to thinking to check the quality of reasoning, including clarit

Clarity

understandable; the meaning can be grasped (“Could elaborate further on that point?”)

Accuracy

Free from errors and distortion; true (“Is that really true”)

Precision

Exact to the necessary level of detail “Could you give more details”)

Relevance

Relating to the matter at hand (“How is that connected to the question”)

Depth

Containing complexities and multiple interrelationships (“Is that dealing with the most significant factors?”)

Breadth

Encompassing multiple viewpoints (“Do we need to consider another point of view”)

Logic

The parts make sense together; no contradictions (“Does this really make sense?”)

Fairness

Justifiable; not self-serving or one-sided (‘Do I have a vested interest in this issue?”)

Purpose of Health Assessment

To determine a client’s overall level of functioning to make a professional clinical judgment

Steps in Preparing for the Assessment

Gathering information BEFORE meeting client

Keep an open mind and avoid premature judgment

Educate yourself about client’s medical diagnosis

Obtain and Organize material needed for assessment

FALSE

(TRUE or FALSE) In preparing for an assessment, gather information DURING or AFTER meeting client

Subjective Data

Information elicited and verified only by the client

Subjective Data

• biographical information

• physical symptoms

• health history

• family history

• lifestyle practices

TRUE

(TRUE or FALSE) Symptoms are considered subjective data

FALSE

(TRUE or FALSE) Signs are considered subjective data

Methods of Validation

• recheck your data

• clarify c client

• verify c another HC professional

• compare objective and subjective findings

Database

Considered the baseline for future diagnosis and nursing care interventions

Database

Becomes the foundation of care for the client, that helps identify health problems and formulate nsg diagnoses and plans

Past

Nurses relied on their natural senses

Present

Depth and scope of nursing assessment has expanded due to advances in medical knowledge and technology

Future

Increased specialization and diversity of assessment skills

Creative Thinking

Goal directed thinking that leads to better solutions by using new ideas or methods