chap 1 Flashcards
ANA standard 1
registered nurse collects comprehensive data pertinent to the patient’s health/situation
ANA standard 2
registered nurse analyzes the assessment data to determine the diagnosis
what do nurses use to arrive at professional clinical judgements?
communication and physical assessment techniques
nursing process
- assessment
- diagnosis
- planning
- implementation
- evaluation
assessment
collect data
diagnosis
analyze data & make judgments
planning
develop a plan
implementation
carry out plan
evaluation
assess outcome & adjus
most crucial step in nursing process
assessment
holistic nursing assessment
-collects holistic subjective data and objective data
physical medical assessment
focuses on the client’s physiologic development status
nurses collect data on
- physiological well-being
- psychological well-being
- sociocultural well-being
- developmental data
- spiritual well-being
framework for health assessment
helps organize info & promotes collection of holistic data
types of health assessments
- initial comprehensive assessment
- ongoing/partial assessment
- focused/problem oriented assessment
- emergency assessment
initial comprehensive assessment
- completed when pt has been admitted to floor
- obtain all possible info about pt
- complete database for problem id and care planning
- past hx
- allergies
- all pertinent physical findings
ongoing/partial assessment
data collection that occurs after the comprehensive database
focused/problem oriented assessment
thorough assessment of particular client problem
emergency assessment
rapid focused assessment
steps of health assessment
- collection of subjective data
- collection of objective data
- validation of data
- documentation data
subjective data
things pt tell you about that you cannot observe
collection of subjective data
- biographical info
- history of present health concerns
- personal health history
- family history
- health & lifestyle practices
- review of systems
objective data
info that is seen, heard, felt, or smelled
collection of objective data
- physical characteristics
- body functions
- appearance
- behavior
- measurements
- results of laboratory testing
physical examination techniques
inspection, palpation, percussion, auscultation
inspection
act of examining/reviewing
palpation
examiner’s hands are used to feel the texture, size, consistency, and location of body parts
percussion
tapping on a surface to determine difference in the density of the underlying structure
auscultation
listening w/ stethoscope
analysis
- identify abnormal data
- cluster data
- draw inferences & identify problems
- propose possible nursing diagnosis
- defining characteristics of diagnosis
- confirm/rule out diagnosis
- document conclusions
models to analyze health promotion and disease prevention
- health belief model
- penders health promotional model
