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Chapter 1

NURS 203 Chapter Notes - Chapter 1: Nursing Process, Health Assessment, Critical Thinking

Course Code
NURS 203
Cheryl Besse

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Jarvis: Physical Examination & Health Assessment, 2nd Canadian
Chapter 01: Critical Thinking and Evidence-Informed Assessment
Key Points
This section discusses key points about assessment and critical thinking.
Assessment is the collection of subjective and objective data about a patient’s
oSubjective data consist of information provided by the affected
oObjective 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 judgement or diagnosis.
Diagnostic reasoning is the process of analyzing health data and drawing
conclusions to identify diagnoses. This process has four major components:
oAttending to initially available cues, which are pieces of information,
signs, symptoms, or laboratory data;
oFormulating diagnostic hypotheses, which are tentative explanations for
a cue or a set of cues and can serve as a basis for further investigation;
oGathering data relative to the tentative hypotheses;
oAnd evaluating each hypothesis with the new data collected, which leads
to a final diagnosis.
The nursing process has 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.
Nurses apply the process differently depending on their level of time and
oThe novice nurse has no experience with specific patient populations and
uses rules to guide performance.
oThe proficient nurse has had more time and experience, understands a
patient situation as a whole rather than as a list of tasks, and envisions long-
term patient goals and nursing actions.
oThe expert nurse has an intuitive grasp of clinical situations and accurate
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