Nursing Data Collection,Documentation And Analysis Flashcards
Nursing process
Assessment
Diagnosis
Planning
Implementation
Evaluation
Gather information and review
Assess
Identify the problem through nursing diagnosis
Diagnose
Set your goals to solve the problem
Planning
Reach the goals through nursing actions
Implementation
Determine the outcomes of the good and what if anything needs changed
Evaluate
Type of health assessment
Initial comprehensive assessment
Problem focused assessment
On going assessment
Emergency assessment
Also known as triage, helps determine the nature of the problem and prepare the way for ensuring assessment stages
Initial comprehensive assessment
Initial comprehensive assessment includes client health history, health status and health related needs
Tuberculosis
Hepatitis
Dental care
Vision care
Home care
It is the documented in case record on forms
Initial comprehensive assessment
Collects data about a problem that has already been identified
Problem- focused assessment
Process of collecting and using standardized information to assess progress towards objectives, resource usage and achievement of results and impacts
On-going assessment
Another type of assessment, take place after initial assessment to evaluate any changes in client functional health. Nurses perform time lapsed reassessment in substantial periods( periodic output patient clinic visit, home health visits,health and development scree)
Time-lapsed assessment
Step of ongoing assessment
-Reassess and record vital signs
-Repeat focused assessment regarding patient complaints and injuries
-check on intervention/treatment in process
The Abccs is the first assessment you will do when you meet your patient
Emergency assessment
