lOMoARcPSD|52942330
Ch16_Nursing_Assessment_Fundamentals_Skills_
Chamberlain_University
, lOMoARcPSD|52942330
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
Ch16_Nursing_Assessment_Fundamentals_Skills_
Chamberlain_University
, lOMoARcPSD|52942330
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
