Chapter 1 Nurse’s Role in Health Assessment:
Collecting and Analyzing Data
Learning Objectives
1. Discuss how nursing assessment skills are needed for every situation the nurse
encounters.
a. As a nurse you will observe situations and collect info to make nursing
judgments no matter whatthe setting. Professional nursing assessments you
make on a client family or community determinenursing interventions that
directly or indirectly influence their health status
2. Differentiate between a holistic nursing assessment and a physical medical
assessment.
a. HOLISTIC- collects holistic subjective & objective data to determine
overall level of functioning to make a nursing diagnosis
i. The nurse assesses the physiologic, psychologic,
sociocultural, developmental, & spiritual data about a client.
ii. The mind, body, & spirit are interdependent factors.
iii. The nurse focuses on how the client's health status affects
ADLs, on how clients interact w/ their family/community, &
how it affects them.
b. Physical medical assessment
i. focuses of physiological status
ii. Less focus may be placed on psychological, sociocultural, or
spiritual well-being.
3. Describe which phases of the nursing process involve assessment by the nurse.
a. Assessment is ongoing and continuous throughout all phases of the nursing
process; therefore all phases of the nursing process involve assessment.
4. List and describe the steps of the nursing process, explaining how some steps
overlap and may have to be repeated many times when caring for a client.
I Assessment Collecting subjective and objective data
Analyzing & synthesizing (combining) data
Making judgements about effectiveness of
nursing interventions
Evaluating client care outcomes
Steps of HA: collect subj. data, collect obj.
data, validate, & documentation.
First & most critical phase
If data is inaccurate, it may cause the nurse to make
incorrect judgements, which can affect the remaining
phases of the process.
Assessment phase is ongoing & continuous throughout
all the phases.
Health assessment consists of health history & physical
examination
II Diagnosis Analyzing subjective and objective data to
make a professional nursing judgment
Collecting and Analyzing Data
Learning Objectives
1. Discuss how nursing assessment skills are needed for every situation the nurse
encounters.
a. As a nurse you will observe situations and collect info to make nursing
judgments no matter whatthe setting. Professional nursing assessments you
make on a client family or community determinenursing interventions that
directly or indirectly influence their health status
2. Differentiate between a holistic nursing assessment and a physical medical
assessment.
a. HOLISTIC- collects holistic subjective & objective data to determine
overall level of functioning to make a nursing diagnosis
i. The nurse assesses the physiologic, psychologic,
sociocultural, developmental, & spiritual data about a client.
ii. The mind, body, & spirit are interdependent factors.
iii. The nurse focuses on how the client's health status affects
ADLs, on how clients interact w/ their family/community, &
how it affects them.
b. Physical medical assessment
i. focuses of physiological status
ii. Less focus may be placed on psychological, sociocultural, or
spiritual well-being.
3. Describe which phases of the nursing process involve assessment by the nurse.
a. Assessment is ongoing and continuous throughout all phases of the nursing
process; therefore all phases of the nursing process involve assessment.
4. List and describe the steps of the nursing process, explaining how some steps
overlap and may have to be repeated many times when caring for a client.
I Assessment Collecting subjective and objective data
Analyzing & synthesizing (combining) data
Making judgements about effectiveness of
nursing interventions
Evaluating client care outcomes
Steps of HA: collect subj. data, collect obj.
data, validate, & documentation.
First & most critical phase
If data is inaccurate, it may cause the nurse to make
incorrect judgements, which can affect the remaining
phases of the process.
Assessment phase is ongoing & continuous throughout
all the phases.
Health assessment consists of health history & physical
examination
II Diagnosis Analyzing subjective and objective data to
make a professional nursing judgment
