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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 |