NUR 326 Health Assessment Exam 1 (Modules 1–4):
Comprehensive Evaluation of Nursing Process
Implementation, Subjective and Objective Data Collection,
Clinical Judgment Development, Health History
Documentation, Interviewing Techniques, Therapeutic
Communication, Cultural and Emotional Considerations,
Patient-Centered Assessment, Diagnostic Reasoning, Data
Validation, Care Planning Strategies, and Evidence-Based
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Assessment
collecting subjective and objective data
diagnosis
analyzing subjective and objective data to make a professional nursing judgement (nursing
diagnosis, collaborative problem or referral)
planning
Determining outcome criteria and developing a plan
implementation
,carrying out the plan
evaluation
Assessing whether outcome criteria have been met and revising the plan as necessary
Preparing for the assessment
• Review the client's record FIRST
- Gives info about educational level, occupation
- Provides background about chronic diseases, ADLs
(activities of daily living), current health status
• Educate yourself about diagnoses, tests
• Avoid premature judgments
- Chronic diseases, drug/alcohol use, lifestyle
• Gather supplies for assessment
subjective data
things a person tells you about that you cannot observe through your senses; symptoms
-health and lifestyle practices
-personal health history
-fam history
-history of present illness
-ROS
,-Biographical info
objective data
direct observations made by the health care professional to evaluate a patient's condition
-physical characteristics
-body functions
-appearance
-behavior
-vital measurements
-results of lab testing
steps of health assessment
Collection of subjective data, collection of objective data, validation of data, documentation
of data, and analysis of data
steps for clinical judgement from asssessment data
1. Identify abnormal cues and supportive cues (client strengths).
2. Cluster cues.
3. Draw inferences to propose or hypothesize clinical judgments (opportunity to improve
health, risk for and actual client concerns/problems, collaborative problems, and/or referral
to primary care provider).
4. Identify possible client concerns.
, 5. Validate the client concern with the client, family, significant others, and/or health team
members.
6. Document clinical judgments
interviewing
establishes rapport and trusting relationship with client to elicit accurate and meaningful info
gathers info on the clients developmental, physiological, psychological, sociocultural and
spiritual status to identify deviations that can be treated with nursing/collaborative
interventions
Preintroductory Phase of Interview
The nurse reviews the medical record before meeting with the client
Introductory phase of interview
-Introduce self
-explain the purpose of interview
-discuss types of questions that will be asked
-explaining the reason for taking notes
-assuring client confidentiality
-making sure client is comfortable and has privacy
-develop trust and rapport using verbal and nonverbal cues