Nursing Process Flashcards
(71 cards)
Is the first step in the nursing process and includes systematic collection, verification, organization, interpretation, and documentation of data for use by healthcare professionals
Assessment
Focus upon the client’s response to health problems, perceived health needs, and health practices and values
Nursing assessments
Is the collection and analysis of data that are used in formulating nursing diagnoses, identifying outcomes, and planning care and developing nursing interventions
The goal of assessment
First phase in the nursing process
Assessment
Systematic gathering of relevant and important patient data; nurse use data to;
Identify health problems
Plan nursing care
Evaluate patient outcomes
5 Elements of the assessment process
Data collection
Data verification
Data organization
Data interpretation
Data documentation
Is the process of gathering information about client, family or community health status
Data collection
Three classifications of collecting data
Interview
Observation
Physical examination
Use printed form (admission database)
Initial assessment
Use nursing model to organize; record on care plan or nursing progress notes
Ongoing assessment
Perform as needed
Special purpose assessment
Is the establish a database about a client’s physical and emotional well-being, and intellectual functioning, social relationships, and spiritual condition.
Purpose of assessment
Supports the use of the nursing process as a standard of practice for registered nurse and outlines the essential components of assessment within the nursing process
The American Nurses Association (ANA)
Client data include information that the client communicates concerning perception of his or her own health status as well as specific observations made by the nurse
Collecting data
Data from the client’s point of view and include feelings, perceptions, and concerns
Subjective data
This data (also referred to as symptoms)
Subjective data
They rely on the feelings or opinions of the person experiencing them and cannot be readily observed by another
Subjective data
Sometimes called covert data or symptoms
Subjective data
Not measurable or observable
Subjective data
Can be obtained only from what the client’s verbalized
Subjective data
Data from significant others
Subjective data
Include client: thoughts, beliefs, feelings, sensation, perception, of self and health
Subjective data
Observable and measurable (quantitative) data that are obtained through observation, standard assessment techniques performed during the physical examination, and laboratory and diagnostic testing
Objective data
This data (also called signs) can be seen heard or felt by someone other than the person experiencing them
Objective data
