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Assessment Exam II


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
Created by: kroberts2750