Assessment is the systematic gathering of information related to the: - Physical, mental, spiritual,
socioeconomic, and cultural status
Assessment includes the 4 following features - collecting data, using a systematic and ongoing process,
categorizing data, recording data
Subjective vs. objective data - subjective- (symptoms) info perceived only by the affected person
objective- (signs) observable and measurable data
when should you validate data? - -subjective/objective data don't agree
-data far outside normal range
-client statements differ at different times in interview
How to conduct an interview: - -individualize approach
-use active listening
-use open ended questions
-avoid health care jargon
-curb your curiosity
-don't give advice/voice opinion
Medical vs. Nursing assessments - Medical assessments- focus on disease/pathology
Nursing assessments- focus on the client's responses to illness
What are nursing diagnoses? - Actual or potential health problems that can be prevented or resolved by
independent nursing intervention
, Medical vs. nursing diagnoses - Medical- describes desease, illness, or injury in which the physician
directs primary treatment
nursing- statement of client health status that nurses can identify, prevent or treat independently
Actual vs. Risk diagnoses - Actual- problem response at the time of assessment, identified by present
signs/symptoms
Risk- Problem response thats likely to develop in vulnerable patient before signs/symptoms due to risk
factors
Maslow's Hiearchy of Basic Human Needs from greatest to least priority: - 1. physical needs
2. security and safety
3. love and belonging
4. self-esteem
5. self actualization (maximum potential)
What are the 3 parts of the Nursing Diagnostic Statement? - -Problem (NANDA)
-Etiology (r/t)
-Defining characteristics (AEB/AMB)
What kind of diagnostic statement is used for risk dx's? - -2 part: problem (NANDA) r/t etiology
What is the most important step in a plan of patient care? - To involve the patient
The Nursing Outcomes Classification (NOC) uses the word outcome as: - any patient response (+or-)
short term vs. long term goals - short term- goals to be achieved within a few hours or days
long term- goals to be achieved within a week, month, or more
what are the components of a goal statement? - subject, action verb, performance criteria, target time,
special conditions
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