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Chapter 16 Nursing Assessment Denise Coffey MSN, RN

Chapter 16 Nursing Assessment Denise Coffey MSN, RN. Critical Thinking Approach to Assessment. Nursing assessment Collection and verification of data Analysis of data Database Consists of client’s perceived needs, health problems, and responses to problems. Data Collection.

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Chapter 16 Nursing Assessment Denise Coffey MSN, RN

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  1. Chapter 16Nursing AssessmentDenise Coffey MSN, RN

  2. Critical Thinking Approach to Assessment • Nursing assessment • Collection and verification of data • Analysis of data • Database • Consists of client’s perceived needs, health problems, and responses to problems

  3. Data Collection • Subjective data • Objective data • Sources of data • Client • Family and significant others • Health care team • Medical records

  4. Methods of Data Collection • Interview • An organized conversation with the client • Nursing health history • Data about the client’s current level of wellness

  5. Nursing Health History

  6. Physical Examination • Observation of client behavior • Diagnostic and laboratory data • Interpreting assessment data and making nursing judgments

  7. Data Documentation • The last component of assessment • Legal and professional responsibility • Requires accurate and approved terminology and abbreviations

  8. Concept Mapping • A visual representation that allows nurses to graphically illustrate the connections between a client’s health problems • Allows nurses to obtain a holistic perspective of health care needs

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