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Chapter 1
Nurse's Role in Health Assessment
14
Nursing
Undergraduate 2
09/07/2016

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Term
What is Assessment?
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
Term
Purpose of Assessment
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
Term
Phases of the Nursing Process
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
Term
Nursing Process
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
Term
Step 1: Assessment
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
Term
Preparing for the Assessment
Definition
*Review client's record
*Keep and open mind
*Reflect on your own feelings
*Educate yourself about client's diagnosis and tests performed
Term
Collection of Subjective Data
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
Term
Collection of Objective Data
Definition
*Physical Characteristics
*Body functions
*Appearance
*Behavior
*Measurements
*Results of laboratory testing
Term
Analysis Phase of Nursing Process
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
Term
Types of Assessment
Definition
*Initial Comprehensive Assessment
*Ongoing or Partial Assessment
*Focused/Problem-Oriented Assessment
*Emergency Assessment
Term
Initial Comprehensive Assessment
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
Term
Ongoing or Partial Assessment
Definition
*Data collection that occurs after the comprehensive database is established
*Ongoing assessment of lung sounds of a lung cancer patient
Term
Focused/Problem-Oriented Assessment
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)
Term
Emergency Assessment
Definition
Very rapid assessment performed in life-threatening situations (ER patient with CP)
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