Nursing Process: Assessment - Nursing Fun Ch 3 Flashcards
What is the difference between a medical diagnoses and nursing diagnoses?
A medical diagnosis focuses on the disease
A nursing diagnosis focuses of the patients response to their illness
An assessment is…
the systematic gathering of information related to the physical, mental, spiritual socioeconomic and cultural status of an individual, group or community.
What is the joint commissions stance/role on assessment?
In agencies where there is an RN on staff, the JCAHO requires that an RN assess patients’ needs for nursing care.
The JCAHO provides detailed standards regarding what and when to assess, including standards that require agencies to provide evidence that:
Assessments are written, comprehensive, and used to identify and assign priorities for care
Agency policy designates when each patient is to be reassessed and which disciplines can make which assessments
all patients are assessed for pain.
Can assessments be delegated?
UAP’s may take temp, height and weight
BUT
it is the RNs responsibility to assign the task, validate the data,conduct the interview and complete the physical assessment
What is subjective data?
Information that can not be measured
(Covert data, symptoms)
information told to the nurse by the client, family, or community including thoughts, beliefs, feelings,and sensations
What is objective data?
Measurable
(Overt data, signs)
gathered through physical assessment, labs or diagnostics i.g. vital signs, x-rays, skin color, urine output
What is primary data?
subjective and objective data obtained from the client
What is secondary data?
subjective and objective data obtained “second-hand”
i.g. medical records from another caregiver, information from a family member, or a UAP
What are the four features common to all definitions of assessment?
Collecting data
Using a systematic and ongoing process
Categorizing the data
Recording the data
