CHAPTER 1 Flashcards
The first and most critical phase of nursing process
Assessment
If the data collection is inadequate, inaccurate clinical judgment may be made that adversely affect the remaining phases of the nursing process
Assessment
Is ongoing and continuous throughout all phases of the nursing process
Assessment
It is more than just gathering information about the health status of the client
Assessment
It is analyzing and synthesizing those data making judgments and about effectiveness of nursing interventions and evaluating client care outcomes
Assessment
Collecting subjective and objective data
Assessment
Analyzing subjective and objective data to make and prioritize professional clinical judgments (client concerns, collaborative problems or referral)
Diagnosis
Generating solutions, developing a plan and determining which outcomes need to be met first
Planning
Taking action. prioritizing and implementing the planned intervention
Implementation
Assessing whether outcomes have been met and revising the plan if the intervention did not make it difference
Evaluation
What are the four basic types of nursing assessment
•Initial comprehensive assessment
•Ongoing or partial assessment
•Focused or problem oriented assessment
•Emergency assessment
Involves collection of subjective data about the client’s perception of their health of all body parts of system, past health history, family history, and lifestyle and health practices
Initial comprehensive assessment
Consists of data collection that occurs after the comprehensive database is established
Ongoing or partial assessment
This consists of a mini overview of the client’s body systems and holistic health patterns of a follow up on health status
Ongoing or partial assessment
Does not replace a comprehensive health assessment
Focused or problem oriented assessment
It is performed when a comprehensive database exists for a client who comes to the healthcare agency with specific health concern
Focused or problem oriented assessment
Consist of thorough assessment of a particular client problem and does not address areas not related to the problem
Focused or problem oriented assessment
Is a very rapid assessment performed in life threatening solutions
Emergency assessment
What are the four major steps of health assessment
Collection of subjective data
Collection of objective data
Validation of data
Documentation of data
Sensation or symptoms, feelings, perceptions, desires, preference, beliefs, ideas, values, and personal information that can be elicited and verified only by the client
Collection of subjective data
What are the six major areas of subjective data
•Biographical information
•History of present health concern
•Personal health history
•Family history
•Health and lifestyle practices
•Review of systems
What are the six directly observes objective data
•Physical characteristics
•Body functioning
•Appearance
•Behavior
•Measurements
•Result of laboratory testing
It is another source of ________is the clients medical health/record, which is the document that contains information about what other health care professionals, observed about the client.
Objective data
It may also be observations noted by the family or SO
Objective data
Is a crucial part of a assessment that often occurs along with collection of subjective and objective data
Validation of data
It serves to ensure that the assessment process is not intended before all relevant data have been collected and helps to prevent documentation of inaccurate data
Validation of data
It forms the database for the entire nursing process and provides data for all other members of the healthcare team
Documentation of data
Is the phase in which the nurse identifies and cluster the cues collected to make clinical judgments
Analysis of data
Is to collect holistic subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment
Purpose of nursing health assessment
Six major steps of process of data analysis
•Identify abnormal cues and supportive cues
•Cluster cues
•Draw inferences, and identify prioritize client concern
•Propose possible collaborative problems to notify the primary care provider
•Identify need for referral to primary care provider
•Document conclusions
