Health Assessment Class 1 2026/03/04
A Database is Formed from
Subjective data, objective data, patients record, laboratory studies. The database
informs clinical judgement and diagnosis.
Diagnostic Reasoning in Health Assessment
Cluster data, abductive reasoning, deductive reasoning, inductive reasoning
Cluster Data
1) Gather assessment cues. Ex. Decreased urine output + Edema + Weight gain
Abductive Reasoning
2) "What could this be?"
Deductive Reasoning
3) "What else should I see?"
Inductive Reasoning
"Have I seen this before?"
Page 1 1 Health Assessment Class 1.pdf
,Health Assessment Class 1 2026/03/04
Clinical Judgement Model
Guides how nursing education builds clinical reasoning in novice nurses
The Nursing Process
5 Step method: ADPIE
Assessment, diagnosis, planning, implementation, evaluation
First-Level Priority Problems
Emergent, life-threatening, immediate problems. Ex. Airway, breathing,
circulation
Second-Level Priority Problems
Next in urgency, requires prompt attention to avoid further deterioration. Ex.
Mental status changes, acute pain, abnormal laboratory results, elimination
problem, risk to safety and security
Third-Level Priority Problems
Important to patient's health but can be addressed after more urgent problems.
May require long-term interventions and collaboration with the patient. Ex.
Knowledge deficits, mobility problems, family coping.
Page 2 2 Health Assessment Class 1.pdf
, Health Assessment Class 1 2026/03/04
Evidence-Based Assessment
1850s: Florence Nightingale using research evidence to improve patient
outcomes.
1970s: "Evidence-based medicine" term defined the context of clinical research
methods.
1970-1980: Focus on "research utilization" which is now termed Evidence-based
practice (EBP)
Assessment skills as foundational to EBP
If you encounter a clinical question, seek new evidence, clinical decision
making= best evidence from literature review + patient's own preference +
clinician's. Gaps in literature, fostering a new culture of EBP
Four types of Patient Databases
Complete (Total Health) Database, Focused or Problem-Centered Database,
Follow-up Database, Emergency Database
Complete (Total Health) Database
Describes current and past health state with complete health history and full
physical exam
Focused or Problem-Centered Database
Limited and Short-Term problems, more targeted, concerning mainly one
problem
Page 3 3 Health Assessment Class 1.pdf
A Database is Formed from
Subjective data, objective data, patients record, laboratory studies. The database
informs clinical judgement and diagnosis.
Diagnostic Reasoning in Health Assessment
Cluster data, abductive reasoning, deductive reasoning, inductive reasoning
Cluster Data
1) Gather assessment cues. Ex. Decreased urine output + Edema + Weight gain
Abductive Reasoning
2) "What could this be?"
Deductive Reasoning
3) "What else should I see?"
Inductive Reasoning
"Have I seen this before?"
Page 1 1 Health Assessment Class 1.pdf
,Health Assessment Class 1 2026/03/04
Clinical Judgement Model
Guides how nursing education builds clinical reasoning in novice nurses
The Nursing Process
5 Step method: ADPIE
Assessment, diagnosis, planning, implementation, evaluation
First-Level Priority Problems
Emergent, life-threatening, immediate problems. Ex. Airway, breathing,
circulation
Second-Level Priority Problems
Next in urgency, requires prompt attention to avoid further deterioration. Ex.
Mental status changes, acute pain, abnormal laboratory results, elimination
problem, risk to safety and security
Third-Level Priority Problems
Important to patient's health but can be addressed after more urgent problems.
May require long-term interventions and collaboration with the patient. Ex.
Knowledge deficits, mobility problems, family coping.
Page 2 2 Health Assessment Class 1.pdf
, Health Assessment Class 1 2026/03/04
Evidence-Based Assessment
1850s: Florence Nightingale using research evidence to improve patient
outcomes.
1970s: "Evidence-based medicine" term defined the context of clinical research
methods.
1970-1980: Focus on "research utilization" which is now termed Evidence-based
practice (EBP)
Assessment skills as foundational to EBP
If you encounter a clinical question, seek new evidence, clinical decision
making= best evidence from literature review + patient's own preference +
clinician's. Gaps in literature, fostering a new culture of EBP
Four types of Patient Databases
Complete (Total Health) Database, Focused or Problem-Centered Database,
Follow-up Database, Emergency Database
Complete (Total Health) Database
Describes current and past health state with complete health history and full
physical exam
Focused or Problem-Centered Database
Limited and Short-Term problems, more targeted, concerning mainly one
problem
Page 3 3 Health Assessment Class 1.pdf
