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Nursing Assessment: Fundamentals and Patient-Centered Care $7.99
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Nursing Assessment: Fundamentals and Patient-Centered Care

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This study guide provides a detailed review of nursing assessment principles from Chapter 16 of the Fundamentals of Nursing curriculum at Chamberlain University. Covering essential topics such as patient-centered care, assessment techniques, data collection, interview skills, and clinical reasoning...

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  • March 26, 2025
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  • 2024/2025
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Chapter 16: Nursing Assessment

Nursing Process: critical thinking 5-step process. ADPIE (assessment, diagnosis (nursing), planning,
implementation, evaluation). A patient-centered care approach, is holistic and essential.

Patient Centered Care: recognizing a patient as the control source & full partner in providing
compassionate/coordinated care based on respect for patient’s preferences, values & needs.

Assessments must be complete, relevant to the condition, & accurate so that the problem can be
correctly identified & resolved.

Critical Thinking Approach to Assessment

Assessment: deliberate & systematic collection of information about a patient to determine the
patients current/past health & functional status and their past/present coping mechanisms.
Includes 2 steps.

1. Collection from a primary & secondary source
2. Interpretation & validation of data to ensure a complete database

Developing the Nurse-Patient Relationship for Data Collection

Information comes from:

-Patient (through interview, observation, physical examination)

-patient is usually best source of information if they are A&O & able to answer
questions without cognitive impairment

-always consider the setting of the assessment & patient’s condition

-important to know the health literacy of the patient

-Family Members/Significant Others (reports & responses to interview)

-primary sources of info for infants/children; critically ill adults; patients who are
mentally handicapped

-only include family when appropriate

-Healthcare Team Members

-Hand-off: interactive process of passing patient-specific info from one caregiver
to another to ensured patient-centered care/safety; chance to collect first set of
info about patient assignment

-Medical Record Information (patient hx, lab work, radiology results, multidisciplinary
consultations

-valuable tool for checking consistency/similarity of data w/ personal
observations

-HIPAA of 1996, enacted in 2003

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