Term
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Definition
*Ability to observe situations and collect information to make nursing judgements
*Occurs no matter the setting; hospital, clinic, home, community, long-term care
*Everyone conducts informal assessments every day (checking weather to decide what to wear)
*Assessment is the foundation of nursing |
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Term
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Definition
*Collect subjective and objective data to determine patient's overall level of functioning
*Helps make professional judgements
*Nurses collect physiologic, psychological, sociocultural, and developmental data... HOLLISTIC DATA |
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Term
| Phases of the Nursing Process |
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Definition
*Assessment: Collecting subjective and objective data
*Diagnosis: Analyzing subjective and objective data to make a professional nursing judgement (nursing diagnosis, collaborative problem, or referral)
*Planning: Determining outcome criteria and developing a plan
*Implementation: Carrying out the plan
*Evaluation: Assessing whether outcome criteria have been met and revising the plan as necessary |
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Term
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Definition
*Nursing process is circular- assessment is ongoing
*Making adjustments depending on patient needs
*When outcome is not anticipated- need to reassess patient, collect new data, and formulate adjustments in plan of care |
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Term
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Definition
*First and most critical phase of nursing process
*If not complete- incorrect nursing judgements, and can effect patient outcomes
*Assessment is ongoing and continuous through all phases of nursing process
*Includes subjective and objective data |
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Term
| Preparing for the Assessment |
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Definition
*Review client's record
*Keep and open mind
*Reflect on your own feelings
*Educate yourself about client's diagnosis and tests performed |
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Term
| Collection of Subjective Data |
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Definition
*Biographical information
*History of present health concern; physical symptoms related to each body part or system
*Past health history
*Family history
*Health and Lifestyle practices |
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Term
| Collection of Objective Data |
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Definition
*Physical Characteristics
*Body functions
*Appearance
*Behavior
*Measurements
*Results of laboratory testing |
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Term
| Analysis Phase of Nursing Process |
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Definition
*Identify abnormal data and strengths
*Cluster the data
*Draw inferences and identify problems
*Propose possible nursing diagnosis
*Confirm or rule out nursing diagnosis
*Document conclusions |
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Term
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Definition
*Initial Comprehensive Assessment
*Ongoing or Partial Assessment
*Focused/Problem-Oriented Assessment
*Emergency Assessment |
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Term
| Initial Comprehensive Assessment |
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Definition
| *Collection of subjective data about the client's perception of health of all body parts or systems, past medical history, family history, and lifestyle and health practices |
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Term
| Ongoing or Partial Assessment |
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Definition
*Data collection that occurs after the comprehensive database is established
*Ongoing assessment of lung sounds of a lung cancer patient |
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Term
| Focused/Problem-Oriented Assessment |
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Definition
| *Thorough assessment of a particular client problem, which does not cover areas not related to the problem (patient coming to clinic for pain, not concerned about dietary habits) |
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Term
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Definition
| Very rapid assessment performed in life-threatening situations (ER patient with CP) |
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