NUR 303: Health Assessment CH. 1, 2, & 3
Assessment the collection of data about an individual's health state
evidence Collected body of data from observations and experiments
subjective data what the person says about himself or herself during history taking
objective data what the health ...
Assessment ✅the collection of data about an individual's health state
evidence ✅Collected body of data from observations and experiments
subjective data ✅what the person says about himself or herself during history taking
objective data ✅what the health professional observes by inspecting, palpating, percussing, and
auscultating during the physical examination
Database ✅elements formed together such as subjective and objective data
the purpose of assessment is to... ✅make a judgment or diagnosis
organized assessment ✅The starting point of diagnostic reasoning
diagnostic reasoning ✅the process of analyzing health data and drawing conclusions to identify
diagnoses
the hypotheticodeductive process has four major components ✅1. attending to initially available cues
2. formulating diagnostic hypotheses
3. gathering data relative to the tentative hypotheses
4. evaluating each hypothesis with the new data collected
cue ✅piece of information, a sign or symptom, or a piece of laboratory data
, Hypothesis ✅a tentative explanation for a cue or a set of cues that can be used as a basis for further
investigation
nursing process ✅standards of practice in nursing that includes six phases
the six phases of the nursing process are... ✅assessment, diagnosis, outcome identification, planning,
implementation, evaluation
First-level priority problems ✅emergent, life-threatening, and immediate, such as establishing an
airway or supporting breathing
Second-level priority problems ✅those that are next in urgency requiring your prompt intervention to
forestall further deterioration. (mental status change, acute pain, acute urinary elimination problem,
untreated medical problems, abnormal lab test results
Third-level priority problems ✅those that are important to the patient's health but can be addressed
after more urgent health problems are addressed. (Knowledge deficit, altered family processes, and low
self esteem) Long term
evidence-based practice (EBP) ✅a problem-solving approach to making clinical decisions, using the best
evidence available; blends both science and art of nursing so best outcomes are achieved; may consist
of specific nursing interventions or use guidelines established for the care of patients
Complete (Total Health) Database ✅Includes complete health history and full physical examination
Describes current and past health state and forms baseline to measure all future changes
Yields first diagnoses
Focused or Problem-Centered Database ✅For limited or short term problem. Collect "mini" database,
smaller in scope, concerns mainly one problem, one cue complex, or one body system
Follow-up database ✅used in all settings to monitor progress of short-term or chronic health problems
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