NURS 210 Chapter 3

Initial Assessment

assessment that is completed when the client first comes to the healthcare agency

Ongoing Assessment

assessment that is performed as needed, at any time after the initial database is completed

ongoing assessment

an assessment that helps identify new problems, follows up on previously identified problems

nutritional, pain, cultural, spiritual health, psychosocial, wellness, family, community, functional ability

what are all the different types of special needs assessments?

graphic flow sheet, intake and output sheet, nursing admission assessment, nursing discharge summary, special-purpose forms, electronic documentation

what are the tools used for recording assessment data?

NANDA-I

What is the nursing diagnosis group that meets every two years and continues the work of refining diagnostic labels and reviewing nursing diagnoses submitted by individuals or nursing organizations?

actual, potential, possible, syndrome, wellness

what are the types of nursing diagnoses?

diagnostic reasoning

the thinking process that enables you to make sense of data gathered during a comprehensive patient assessment

medical diagnosis

describes a disease, illness, or injury. its purpose is to identify a pathology so that appropriate treatment can be given

collaborative problem

determined by medical diagnosis or pathology and is a potential event that nurses monitor to detect onset or changes in status. managed by physician-prescribed and nursing-prescribed interventions to minimize the complications.

actual nursing diagnosis

a problem response that exists at the time of the assessment

risk (potential) nursing diagnosis

a problem response that is likely to develop in a vulnerable patient if the nurse and patient do not intervene to prevent it.

possible nursing diagnosis

use when your intuition and experience direct you to suspect that a diagnosis is present, but you so not have enough cues to support the diagnosis.

syndrome nursing diagnosis

represents a collection of nursing diagnoses that usually occur together

patient strengths

data include history and observations during assessment, noticing this helps support recovery and healing.

wellness nursing diagnosis

describes health status but does not describe a problem; can apply to an individual, family, group, or community