Unit 1 A: THE NURSE’S ROLE IN HEALTH ASSESSMENT and Unit 1 B: Critical thinking in Health assessment Flashcards
§ The gathering of information about a
patient’s physiological, psychological,
sociocultural, development & spiritual
status
§ Purpose: To collect subjective & objective
data to determine a client’s overall level of
functioning in order to make a professional
clinical judgement
Assessment
collection of subjective data
about the client’s perception of
ALL body parts or systems, past
health hx, family hx, & lifestyle &
health practices plus gathering
of objective data during a stepby-step physical examination
Type of assessment?
Initial or comprehensive assessment
a. data collection after
comprehensive assessment
b. any problems that were initially
detected in the client’s body
system are reassessed in lessdepth to determine any major
changes from the baseline
Ongoing or Partial assesment
a. data collection after
comprehensive assessment
b. any problems that were initially
detected in the client’s body
system are reassessed in lessdepth to determine any major
changes from the baseline
Focused or Problem oriented asssessment
a. very-rapid assessment
performed in life- threatening
situations (e.g choking,
drowning)
b. an immediate diagnosis is
needed to provide prompt
treatment
c. example: assessment of ABC’s
Emergency Assessment
Four Major steps of Health assessment?
- Collection of Subejctive data
- Collection of Objective data
- Validation of data
- Documentation of data
Methods of validation
o recheck your own data
o clarify data w/ the client ( ask
additional questions)
o verify with another HC
professional
o compare objective from
subjective findings
Meaning of ADPIE?
Assessment
Diagnosis
Planning
Implementation
Evaluation
data that is elicited and verified ONLY by patient thru client interview
Subjective data
data that is ibtained by nurse or examiner
Objective data
§ a purposeful mental activity (problem –
solving & decision- making ) that guides
beliefs and actions
§ is “ thinking about you thinking while
you’re thinking in order to make your
thinking better
§ is self-directed, self-disciplines, selfmonitored, and self- corrective thinking
Critical thinking
a major component
in critical thinking.
§ goal directed thinking that leads to better
solutions by using new ideas or methods
Creative thinking
Meaning of COLDSPA?
Characteristics, Onset, Location, Duration, Severity, Pattern, Associated signs and symtoms
What are the Universal Intellectual Standards For Critical
Thinking
clarity
accuracy
precision
relevance
depth
breadth
logic
fairness
What is the source of holistic, accurate and effective nursing?
It is the 1st and most critical step in health Assessment
Health Assessment
