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Assessment Exam II
Assessment
Question | Answer |
---|---|
Steps of nursing process | 1. Assessment 2. Nursing diagnosis 3. Planning 4. Implementation 5. Evaluation |
Define nursing process | a systematic, rational method of planning and providing nursing care. |
Nursing process | Orderly, logical approach to providing nursing care and ensuring that patient needs are met. |
Assessment | collect, organize, validate and document patient data |
Diagnosing | Analyze and synthesize data |
Planning | Determine how to prevent, reduce, and resolve client problems |
IMPLEMENTING | Perform planned nursing interventions, reassessment of the patient and documentation |
EVALUATION | Measure the degree to which goals have been achieved |
4 types of assessments | 1. Initial 2. Problem-focused 3. Emergency 4. Time-lapsed reassessment |
Collecting Data | Gathering information about client’s health status Where? - physical assessment - Primary Health care providers history and physical - Results of labs and diagnostics - Healthcare teams documentation |
Organizing Data | Writing data into an organized format |
Validating Data | Verifying that data is complete and accurate |
Documenting Data | Recording data in a factual manner |
Nursing health history | Biographic data Chief complaint or reason for visit History of present illness Past history Family history of illness Lifestyle Social Data Psychological Data Patterns of Health Care |
Subjective data | Symptoms Described, verified by the person affected Includes: sensations, feelings, values, beliefs, attitudes and perceptions |
Objective data | Signs Can be observed, measured, & tested Obtained by Observation or physical examination |
Sources of data | Client Support People Client Records Health Care Professionals Literature |
Data collecting methods | Observing Interviewing Examining |