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Nursing Process
A systematic approach to providing nursing care, consisting of five phases:assessment, diagnosis, planning, implementation, and evaluation.
Objective Data
Information obtained through observation, physical examination, and review of the patient's health record.
Ongoing or Partial Assessment
Data collection after the initial comprehensive assessment, focusing on reassessing any problems detected in the client's body system.
Focused or Problem-Oriented Assessment
A thorough assessment of a particular client problem, excluding areas not related to the problem.
Emergency Assessment
A rapid assessment performed in life-threatening situations, requiring an immediate diagnosis for prompt treatment.
Collection of Subjective Data
The first step of health assessment, involving the gathering of information about the patient's biographical information, physical symptoms, past health history, family history, and health and lifestyle practices.
Collection of Objective Data
The second step of health assessment, involving the observation of physical characteristics, body functions, appearance, behavior, measurements, and laboratory results.
Validation of Data
The process of confirming or verifying that the subjective and objective data gathered are reliable, accurate, and complete.
Documentation of Data
The process of recording the gathered data to provide a database for the healthcare team, helping to identify health problems, formulate nursing diagnoses, and plan care.
Critical Thinking
Purposeful mental activity that guides beliefs and actions, involving problem-solving, decision-making, self-directed, self-disciplined, self-monitored, and self-corrective thinking.
Universal Intellectual Standards for Critical Thinking
Standards that must be applied to thinking to check the quality of reasoning, including clarit
Clarity
understandable; the meaning can be grasped (“Could elaborate further on that point?”)
Accuracy
Free from errors and distortion; true (“Is that really true”)
Precision
Exact to the necessary level of detail “Could you give more details”)
Relevance
Relating to the matter at hand (“How is that connected to the question”)
Depth
Containing complexities and multiple interrelationships (“Is that dealing with the most significant factors?”)
Breadth
Encompassing multiple viewpoints (“Do we need to consider another point of view”)
Logic
The parts make sense together; no contradictions (“Does this really make sense?”)
Fairness
Justifiable; not self-serving or one-sided (‘Do I have a vested interest in this issue?”)
Purpose of Health Assessment
To determine a client’s overall level of functioning to make a professional clinical judgment
Steps in Preparing for the Assessment
Gathering information BEFORE meeting client
Keep an open mind and avoid premature judgment
Educate yourself about client’s medical diagnosis
Obtain and Organize material needed for assessment
FALSE
(TRUE or FALSE) In preparing for an assessment, gather information DURING or AFTER meeting client
Subjective Data
Information elicited and verified only by the client
Subjective Data
biographical information
physical symptoms
health history
family history
lifestyle practices
TRUE
(TRUE or FALSE) Symptoms are considered subjective data
FALSE
(TRUE or FALSE) Signs are considered subjective data
Methods of Validation
recheck your data
clarify c client
verify c another HC professional
compare objective and subjective findings
Database
Considered the baseline for future diagnosis and nursing care interventions
Database
Becomes the foundation of care for the client, that helps identify health problems and formulate nsg diagnoses and plans
Past
Nurses relied on their natural senses
Present
Depth and scope of nursing assessment has expanded due to advances in medical knowledge and technology
Future
Increased specialization and diversity of assessment skills
Creative Thinking
Goal directed thinking that leads to better solutions by using new ideas or methods