Nursing Assessment 3009 Chapter 1

The collection of data about an individual's health state.

The Western European/North American tradition that views health as the absence of disease.

A complete health history and full physical examination.

Simultaneously problem-solving while self-improving one's own thinking ability.

• A method of collecting and analyzing clinical information with the following 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.
• 5-Arriving at a final diagnosis.

Rapid collection of the database, often compiled concurrently with lifesaving measures.

The total of all the conditions that make up the surrounding and influence the development of a person.

EBP-A systematic approach emphasizing the best research evidence, the clinician's experience, patient preference and values, physical examination and assessment.

One used for a limited or shot-term problem; Concerns mainly one problem, one cue complex, or one body system.

Used in all settings to monitor progress on short-term or chronic health problems.

The view that the mind, body, and spirit are interdependent and function as a whole within the environment.

Used to evaluate the cause and etiology of disease; focus is on the function or malfunction of a specific organ system.

Used to evaluate the response of the whole person to actual or potential health problems.

• A method of collecting and analyzing clinical information with the following components:
• 1-Assessment
• 2-Diagnosis
• 3-Outcome of Identification
• 4-Planning
• 5-Implementation
• 6-Evaluation

What the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination.

Any action directed toward promoting health and preventing the occurrence of disease.

What the person says about him or herself during history taking.

A dynamic process and view of health; a move toward optimal functioning.

• Collect data
•     Review of the clinical record
•     Health History
•     Physical Examination
•     Functional Assessment
•     Risk Assessment
•     Review of Literature
• Use evidence based assessment techniques
• Document relevant data

• Compare clinical findings with normal and abnormal variation and developmental events
• Interpret Data
•     ID clusters or cues
•     Make Hypotheses
•     Test Hypotheses
•     Derive Diagnoses
• Validate Diagnoses
• Document Diagnoses

• Identify expected outcomes
• Individualize the the person
• Culturally appropriate
• Realistic and measurable
• Incluse a time line

• Establish priorities
• Develop outcomes
• Set timelines for outcomes
• ID interventions
• Integrate evidence-based trends and research
• Document plan of care

• Implement in a safe and timely manner
• Use Evidence-based interventions
• Collaborate with colleagues
• Use community resources
• Coordinate care delivery
• Provide health teaching and health promotion
• Document implementation and any modification

• Progress toward outcomes
• Conduct systemic, ongoing, criterion-based evaluation
• Include patient and significant others
• Use ongoing assessment to revise diagnoses, outcomes, plan
• Disseminate results to patient and family