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Nursing Assesment (NSE 13) Lecture Notes - Chapter 1

John Marsh
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Ryerson University

Nursing Assesment (NSE 13)

Nursing Assesment – Lecture notes – Chapter 1

NSE 13: Week 1
Assessment: The collection of data about the individual’s health state (subjective and
Subjective Data: What the person says about himself or herself during history taking
Objective Data: What health care professionals observe by inspecting, percussing,
palpating and
auscultating during the physical exam.
The Database:
 The database consists of the patient’s records and lab studies.
 With the database you can make a clinical judgement or diagnosis about the individual’s
health state or response to actual or risk health problems and life processes as well as
diagnoses about higher levels of wellness
Purpose of Assessment:
 To make a judgement or diagnosis.
 The starting point of every approach to clinical reasoning is an organized assessment
 It is important that your assessment be factual and complete because all healthcare treatments
and decisions are made based on the data you gather during assessment
Diagnostic Reasoning in Clinical Judgement:
 Most beginning examiners perform well in gathering data, given adequate practice, but then
treat all the data as being equally important- this makes the decision making slow and
Diagnostic Reasoning
 is the process of analyzing health data and drawing conclusions to identify diagnoses- it is
based on the scientific method.
 Diagnostic Reasoning has 4 major components:
1. Attending to Initially Available Cues: A cue is a piece of information, a sign or a
symptom or a piece of laboratory data
2. Formulating Diagnostic Hypotheses: A hypothesis is a tentative explanation for a
cue or a set of cues that can be used as a basis for further investigation
3. Gathering Data Relative to the Tentative Hypothesis: You gather to support or
reject the tentative hypothesis
4. Evaluating Each Hypothesis with the New Data Collected: thus arriving at a final
 Once you complete data collection, develop a preliminary list of significant signs and
symptoms and all patient health needs.
 Cluster or group the assessment data that appear to causal or associated. For example, a
person with acute pain: associated data may include rapid heart rate and anxiety
 Validate the data you collect to make sure they are accurate
Nursing Process in Clinical Judgement
6 phases of the Nursing Process:
NSE 13: Week 1
1. Assessment 2. Diagnosis 3. Outcome Identification 4. Planning
5. Implementation 6. Evaluation
 Today we consider the nursing process to be a dynamic interactive process. In today’s
complex clinical setting, practitioners move back and forth within the steps.
 The novice nurse has no experience with a specified patient population and uses rules to
guide performance.
 With more time and experience, the proficient nurse understands a patient situation as a
whole rather than as a list of tasks. The nurse sees long term goals for the patient
 Expert nurses vault over the steps and arrive at clinical judgement in one leap
Nursing Process in detail:
1. Assessment:
 Collect data:
 Review the clinical record
 Interview
 Health history
 Physical examination
 Functional assessment
 Consultation
 Review of the literature
2. Diagnosis
 Interpret Data:
 Indentify clusters of cues
 Make inferences
 Validate inferences
 Compare clusters of cues with definition and defining characteristics
 Identify related factors
 Document the diagnosis
3. Outcome Identification:
 Identify expected outcomes
 Individualize to the person
 Ensure realistic and measurable outcomes
 Include a time frame



Nursing Assesment (NSE 13) Lecture Notes - Chapter 1

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