Assessment Flashcards
What is the diff between a medical and nursing diagnoses?
A medical diagnosis focuses on the disease.
A nursing diagnosis focuses on the patients response to their illness.
What is an assessment?
The systematic gathering of information related to the physical, mental, spiritual, socioeconomic and culture status of an individual, group, or community.
What is the joint commissions role on assessment?
In agencies where there is an RN on staff, the JCAHO requires that an RN assess patients’ needs for nursing care. The JCAHO provides detailed standards regarding what and when to assess, including standards that require agencies to provide evidence that: Assessments are written, comprehensive, and used to identify and assign priorities for care Agency policy designates when each patient is to be reassessed and which disciplines can make which assessments all patients are assessed for pain.
Can assessments be delegated?
UAP’s may take temp, height, and weight. BUT it is RNs responsibility to assign the task, validate the data, conduct the interview and complete physical assessment.
What is subjective data?
Information that cannot be measured (covert data & symptoms)
Information told to the nurse by the client, family, or community including thoughts, beliefs, feelings, and sensations.
What is objective data?
Measurable (overt data) gathered through physical assessment, labs, or diagnostics. I.e., vital signs, x-rays, skin colour, urine, etc.
What is primary data?
Subjective and objective data obtained from the client.
What is secondary data?
Subjective and objective data obtained second-hand. I.e., medical records from another caregiver, family members, UAP.
What are the four common features common to all definitions of assessment?
Collecting data.
Using a systematic and ongoing process.
Categorizing the data.
Recording the data.
