Primary Care Interprofessional Collaborative Practice
7th Edition (Buttaro, 2025), Chapter 1-228 | Complete
Guide A+
______________________________________________________________________________
The Nurse's Role in Health Assessment
Phases of the Nursing Process
1. Assessment: Collecting subjective and objective data
2. Diagnosis: Analyzing subjective and objective data to make a professional nursing judgment
(nursing diagnosis, collaborative problem, or referral)
3. Planning: Determining outcome criteria and developing a planterm-4
4. Implementation: Carrying out the plan
5. Evaluation: Assessing whether outcome criteria have been met and revising the plan as
necessary
Step 1 of the Nursing Process
-assessment
-First and most critical phase
-Collecting subjective and objective data
-May lead to inadequate or inaccurate, incorrect clinical judgments if completed incorrectly
-Is ongoing and continuous throughout all phases
-More than just gathering information
Physical Medical Asssessment
Focuses primarily on the client's physiologic development status
Holistic nursing assessment
1|Page
,-Collects holistic subjective and objective data to determine a client's overall level of functioning
in order to make a professional clinical judgment
-Mind, body, and spirit interdependent factors that affect each client's level of health
Physical assessment vs holistic assessment
Holistic nursing assessment collects holistic subjective and objective data to determine a client's
overall level of functioning in order to make a professional clinical judgment.
Physical medical assessment focuses primarily on the client's physiologic development status.
Types of Health Assessments
1. Initial comprehensive assessment
2. ongoing or partial assessment
3. focused or problem-oriented assessment
4. emergency assessment
Initial Comprehensive Assessment
-Subjective data
-Past health history
-Family history
-Lifestyle and health practices
-Objective data
-Frequency of comprehensive assessments depends on age, risk factors, health status, health
promotion practices, lifestyle
Ongoing or Partial Assessment
-Continued data collection after comprehensive assessment
-Mini overview
-Reassessed any problems
-Detect any new problems
2|Page
,Focused or Problem-Oriented Assessment
-Does not replace comprehensive assessment
-Thorough assessment of particular client problem
-Does not address areas not related to problem
Emergency Assessment
-Very rapid assessment in life-threatening situations
-Goal—provide prompt treatment
-Only concern is preventing death
4 major steps of health assessment
1. Collection of subjective data
2. collection of objective data
3. validation of data
4. documentation data
steps tend to overlap
may perform 2 or 3 steps concurrently
Preparing for the health assessment
-Review client's record
-Review client's status with other health care team members
-Educate about client's diagnosis and tests performed
-Reflect on your personal feelings regarding initial encounter with client
-Obtain and organize materials needed for assessment
Collecting Subjective Data
-Biographical information
-History of present health concern; physical symptoms related to each body part or system
-Personal health history
3|Page
, -Family history
-Health and lifestyle practices
-Review of systems
Collecting Objective Data
-Physical characteristics
-Body functions
-Appearance
-Behavior
-Measurements
-Results of laboratory testing
Validating Assessment Data
-Crucial part of assessment
-Ensures assessment process is not ended before all relevant data have been collected
-Helps prevent documentation of inaccurate data
Documenting Data
-Forms the database for entire nursing process
-Provides data for all other members of health care team
-Ensures valid conclusions are made
What are cues?
-Pieces of data collected during assessment that get the nurse's attention
-Data can be abnormal or normal but pertinent to what is going on with the client
What does "clustering cues" mean?
means putting pieces of data together that belong together
Analyzing Cues to Identify Client Concerns Using the Clinical Judgement Model
4|Page
7th Edition (Buttaro, 2025), Chapter 1-228 | Complete
Guide A+
______________________________________________________________________________
The Nurse's Role in Health Assessment
Phases of the Nursing Process
1. Assessment: Collecting subjective and objective data
2. Diagnosis: Analyzing subjective and objective data to make a professional nursing judgment
(nursing diagnosis, collaborative problem, or referral)
3. Planning: Determining outcome criteria and developing a planterm-4
4. Implementation: Carrying out the plan
5. Evaluation: Assessing whether outcome criteria have been met and revising the plan as
necessary
Step 1 of the Nursing Process
-assessment
-First and most critical phase
-Collecting subjective and objective data
-May lead to inadequate or inaccurate, incorrect clinical judgments if completed incorrectly
-Is ongoing and continuous throughout all phases
-More than just gathering information
Physical Medical Asssessment
Focuses primarily on the client's physiologic development status
Holistic nursing assessment
1|Page
,-Collects holistic subjective and objective data to determine a client's overall level of functioning
in order to make a professional clinical judgment
-Mind, body, and spirit interdependent factors that affect each client's level of health
Physical assessment vs holistic assessment
Holistic nursing assessment collects holistic subjective and objective data to determine a client's
overall level of functioning in order to make a professional clinical judgment.
Physical medical assessment focuses primarily on the client's physiologic development status.
Types of Health Assessments
1. Initial comprehensive assessment
2. ongoing or partial assessment
3. focused or problem-oriented assessment
4. emergency assessment
Initial Comprehensive Assessment
-Subjective data
-Past health history
-Family history
-Lifestyle and health practices
-Objective data
-Frequency of comprehensive assessments depends on age, risk factors, health status, health
promotion practices, lifestyle
Ongoing or Partial Assessment
-Continued data collection after comprehensive assessment
-Mini overview
-Reassessed any problems
-Detect any new problems
2|Page
,Focused or Problem-Oriented Assessment
-Does not replace comprehensive assessment
-Thorough assessment of particular client problem
-Does not address areas not related to problem
Emergency Assessment
-Very rapid assessment in life-threatening situations
-Goal—provide prompt treatment
-Only concern is preventing death
4 major steps of health assessment
1. Collection of subjective data
2. collection of objective data
3. validation of data
4. documentation data
steps tend to overlap
may perform 2 or 3 steps concurrently
Preparing for the health assessment
-Review client's record
-Review client's status with other health care team members
-Educate about client's diagnosis and tests performed
-Reflect on your personal feelings regarding initial encounter with client
-Obtain and organize materials needed for assessment
Collecting Subjective Data
-Biographical information
-History of present health concern; physical symptoms related to each body part or system
-Personal health history
3|Page
, -Family history
-Health and lifestyle practices
-Review of systems
Collecting Objective Data
-Physical characteristics
-Body functions
-Appearance
-Behavior
-Measurements
-Results of laboratory testing
Validating Assessment Data
-Crucial part of assessment
-Ensures assessment process is not ended before all relevant data have been collected
-Helps prevent documentation of inaccurate data
Documenting Data
-Forms the database for entire nursing process
-Provides data for all other members of health care team
-Ensures valid conclusions are made
What are cues?
-Pieces of data collected during assessment that get the nurse's attention
-Data can be abnormal or normal but pertinent to what is going on with the client
What does "clustering cues" mean?
means putting pieces of data together that belong together
Analyzing Cues to Identify Client Concerns Using the Clinical Judgement Model
4|Page
