Jarvis: Physical Examination & Health Assessment, 6th Edition

Chapter 1: Evidence-Based Assessment

Key Points – Print

This section discusses key points about assessment and critical thinking.
⦁ Assessment is the collection of subjective and objective data about a patient’s health. ⦁ Subjective data consist of information provided by the affected individual. 1 Objective data include information obtained by the health care provider through physical assessment, the patient’s record, and laboratory studies.
⦁ The database is the totality of information available about the patient. The purpose of assessment is to make a judgment or diagnosis.
1 Diagnostic reasoning is the process of analyzing health data and drawing conclusions to identify diagnoses. This process has four major components: ⦁ Attending to initially available cues, which are pieces of information, signs, symptoms, or laboratory data; 1 Formulating diagnostic hypotheses, which are tentative explanations for a cue or a set of cues and can serve as a basis for further investigation; 2 Gathering data relative to the tentative hypotheses; 3 And evaluating each hypothesis with the new data collected, which leads to a final diagnosis.
⦁ The nursing process includes six phases: assessment, diagnosis, outcome identification, planning, implementation, and evaluation. It is a dynamic, interactive process in which practitioners move back and forth within the steps.
1 Nurses apply the process differently depending on their level of time and experience. ⦁ The novice nurse has no experience with specific patient populations and uses rules to guide performance. 1 The experienced nurse understands a patient situation as a whole rather than as a list of tasks, attends to an assessment data pattern, and acts without consciously labeling it.
⦁ Critical thinking is the