Chapter 1 - Key Points in Assessment and Diagnostic Process PDF

Chapter 1—Key Points This section discusses key points about assessment and Second-level priority problems are next in urgency. the diagnostic process. They require prompt intervention to prevent further Assessm...

Chapter 1—Key Points This section discusses key points about assessment and Second-level priority problems are next in urgency. the diagnostic process. They require prompt intervention to prevent further Assessment is the collection of subjective and objective deterioration and may include mental status change, data about a patient’s health. acute pain, or abnormal laboratory values in the Subjective data consist of information provided by patient. the affected individual. Third-level priority problems are important to the Objective data include information obtained by the patient’s health but can be addressed after more health care provider through observation and urgent problems. Examples include lack of knowledge inspecting, percussing, palpating, and auscultating or family coping. during the physical examination. Collaborative problems are certain physiologic The database is the totality of information available conditions in which the approach to treatment about the patient, including subjective data, objective involves multiple disciplines. data, and the patient’s medical record and laboratory studies. The purpose of assessment is to make a This section presents critical points about evidence-based judgment or diagnosis. assessment. Once data collection is completed, cluster or group Evidence-based practice is a systematic approach to together assessment data that is associated, and then practice that uses research evidence, clinical expertise, validate the data to ensure it is accurate. clinician knowledge, and the patient’s preferences and The nursing process includes six phases: assessment, values to make decisions about care and treatment. diagnosis, outcome identification, planning, Every examiner needs to collect four types of databases implementation, and evaluation. It is a dynamic, based on the situation. interactive process in which practitioners move back and A complete (or total health) database includes a forth within the steps. complete health history and a full physical Nurses apply the process differently depending on their examination, yielding the first diagnoses. level of experience. A focused (or problem-centered) database is used for The novice nurse has no experience with specific a limited or short-term problem. It is smaller in scope patient populations and uses rules to guide and more targeted than the complete database. performance and achieve competency. A follow-up database evaluates the status of any The proficient nurse understands a patient situation identified problem at regular intervals to follow up on as a whole rather than as a list of tasks, attends to an short-term and chronic health problems. assessment data pattern, and acts without consciously An emergency database calls for rapid collection of labeling it. crucial data, which often occurs while performing The expert nurse has an intuitive grasp of a clinical lifesaving measures. situation and zeroes in on the accurate solution. Critical thinking is sound diagnostic reasoning and clinical judgment. Relevant information should be identified, clinical cues gathered, the assessment completed, and priorities considered. First-level priority problems are emergent, life- threatening, and immediate, such as establishing an airway or supporting breathing. Critical thinking is required for sound diagnostic reasoning and clinical judgment. Copyright © 2024 by Elsevier Inc. All rights reserved.