Data Collection, Decision Making and General Survey Flashcards
Assessment
Systematic and deliberate collection of data in order to determine a client’s health status. Need an objective source of data, understand what’s going on. Consider physical state and health history.
Nursing diagnosis
Diagnosis of care and condition.
Medical diagnosis
Medical diagnosis of a condition
Critical Thinking
Make sure there is enough information for data collection to determine change. Think about observation and information related to experience, verifying information, conclusion, actions, decisions and making thought process better.
Data collection
Based on the ability to critically think clinical knowledge, experience, health history and responses. Questions and measurements are needed. Know what is important.
Client cue
A non verbal indication. Can be the smell of an infection.
Inferences
Interpretation of cues, it is subjective information of a patient. It is a primary source.
Objective of data collection
Observations and measurements. Inspecting, observing behaviour, TPR, BP, Bgn, lab test, physical exams.
Primary source
Often client unless unconscious, is a minor, poor cognitive capacity, needing interpreter, or is critically ill.
Secondary Source
Includes family, significant others, other health care workers, medical charts, cleaning staff, bystanders, literature review, experience and coworkers. Confirms findings of client.
Methods of Data collection
- Interview
- Observation
- Physical exam
- Frameworks
What is the client’s strength?
Strength, emotional capacity and support.
Nursing Process
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
