NUR 310 Health Assessment EXAM 1
what are the 6 steps of the nursing process? 1. assessment
2. diagnosis
3. outcome identification
4. planning
5. implementation
6. evaluation
what is the standards of practice of nursing? the nursing process
what is assessment? *collecting data
...
what are the 6 steps of the nursing process? ✅1. assessment
2. diagnosis
3. outcome identification
4. planning
5. implementation
6. evaluation
what is the standards of practice of nursing? ✅the nursing process
what is assessment? ✅*collecting data
*using evidence based techniques
*using relevant document data
what is diagnosis? ✅*comparing critical findings
*abnormal v.s normal findings
*interpret data
*validate and document the diagnosis
what is outcome identification? ✅*individualize the patient
*realistic/expected outcomes
*timeline
what is planning? ✅*priorites
*outcomes
*interventions
,*integrate the research and evidence
what is implementation? ✅*collaberate with colleagues
*health teachings
*do so in a safe timely manner
what is evaluation? ✅*include the patient and loved ones
*give results to the patient and family
*progress toward outcomes
health assessment is characterized into what two types of data? ✅1. subjective date
2. objective data
what is subjective data? and an example of it ✅what the person says about themselves during history
taking
ex: "I feel dizzy"
what is objective data? and an example of it? ✅what the health professional observes by inspection,
palpation, and auscultation during the physical
which kind of data supports the other? ✅objective data can support subjective data
why is it important that assessments are thorough, organized, and accurate? ✅health care diagnosis,
descions, and treatments are based on your data
what is a nursing diagnosis? ✅describes a patient actual or potential health problems that a nurse can
identify
what are the four types of problems you will experience? ✅1. first level priority problems
2. second level priority problems
, 3. third level priority problems
4. collaborative problems
what are first level priority problems? and an example? ✅problems that are emergent, life threatening,
and require immediate attention
example: supporting breathing
what are second level priority problems? and an example? ✅*next in urgency
*needs your intervention to prevent further deterioration
*example: acute pain, risk of safety, mental status change, untreated medical problems
what are third level priority problems? and an example? ✅important to the patients health but can be
attended to after the more urgent issues
*interventions to treat these problems are more long term
what are collaborative problems? ✅an effort between patient and health care professionals to discuss
appropriate care for the patient
what are the collecting four types of data? ✅1. complete (total health) database
2. focus (problem centered) database
3. follow up data base
4. emergency data base
what is complete (total health) database? and an example? ✅includes complete health history and a full
physical
ex: performed in a primary care setting such as a family care or private practice
what is focused (problem-centered) database? and an example? ✅*for a limited or short term problem,
"mini database"
*more targeted than other databases
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