Chapter 5: Assessment, Data Analysis/Problem Identification, and Planning

Vocabulary flashcards covering the nursing process stages of assessment, diagnosis, and planning, including data collection methods and goal setting.

Assessment (Data Collection)

The process where the nurse collects patient health data, organizes it into a database, and documents it.

Functional health patterns assessment

An approach to assessment as formulated by Mary Gordon.

Focused assessment

An assessment approach that focuses on a specific problem.

Basic needs assessment

An assessment approach based on Maslow’s hierarchy of basic needs.

The Interview

A communication-based process for gathering data that is not a social interaction, consisting of verbal and nonverbal components.

Opening (Interview Stage)

The first stage of an interview during which rapport is established with the patient.

Body (Interview Stage)

The middle stage of an interview during which necessary questions are presented.

Closing (Interview Stage)

The final stage of an interview during which information is summarized.

Medical Records (Chart) Review

A data collection tool that helps obtain information to interview a patient or prepare for the day’s patient assignment.

Physical Assessment

A systematic examination, such as a head-to-toe examination, using techniques of inspection, auscultation, palpation, and percussion.

Symptom

A subjective indication of illness perceived by the patient that cannot be verified by examination.

Sign

Abnormalities that can be verified by repeat examination and are considered objective data.

Analysis

The process of analyzing the database for cues that deviate from the norm, sorting and clustering data, and identifying missing data.

Nursing Diagnosis Statement

A statement indicating the patient's actual health status or risk, causative factors, and specific defining characteristics (signs and symptoms).

Etiologic Factors

The causes of the patient's problem.

Defining Characteristics

The signs and symptoms that must be present for a particular problem statement to be appropriate and valid for a patient.

Prioritization of Problems

The ranking of problems according to importance, where physiologic needs for basic survival (airway and circulation) take precedence.

Goal

What is to be achieved by nursing intervention.

Short-term goals

Goals achievable within $7$ to $10$ days or before discharge.

Long-term goals

Goals that take many weeks or months to achieve and often relate to rehabilitation.

Expected outcome

A statement of the goal a patient is to achieve as a result of nursing intervention, used to measure the effectiveness of interventions.

Interventions (Nursing Orders)

Individualized activities designed to alleviate problems and achieve expected outcomes, including giving medications and performing treatments.

Nursing Care Plan Review

The process of updating and reviewing the plan of care, which should be performed once every $24$ hours.