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1. Explain how assessment is applicable to every situation the nurse encounters.
Assessment: the collection of comprehensive data pertinent to the patient's health or the situation. Data collection should be systematic and ongoing. As applicable, evidence-based assessment tools or instruments should be used for example evidence-based fall assessment tool, pain rating scales or wound assessment tools.
2. Differentiate between a nursing assessment and a medical assessment.
- Nursing assessment
- Collective subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment
- Medical assessment
- Focuses primarily on the client's physiologic development status
3. Describe how assessment fits into the total nursing process.
First step of the Nursing Process, assessment is collecting subjective and objective data, nurse collects factors that affect a person's level of health
4. List and describe the steps of the nursing process
- Nursing Process:
- 1. Assessment- Collecting subjective and objective data
- 2. Diagnosis- Analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, or referral)
- 3. Planning- Determining outcome criteria and developing a plan
- 4. Implementation- Carrying out the plan
- 5. Evaluation- Assessing whether outcome criteria have been met and revising the plan as necessary
4b. Steps of the assessment phase:
- The assessment phase of the nursing process has four major steps:
- 1. Collection of subjective data- Biographical information, Physical symptoms related to each body part or system, Past health history, Family history, Health and lifestyle practices, feelings, perception, info given by the client
- 2. Collection of objective data- Physical characteristics, Body functions, Appearance, Behavior, Measurements, Results of laboratory testing, directly observed by the examiner, obtained by observation & examination
- 3. Validation of data- along with collection of obj/sub data validate data
- 4. Documentation of data- always! Important because it forms the database for the entire nursing process and provides information for all others of the HC team
5. Describe the steps of the analysis phase of the nursing process.
- 1. Identify abnormal data and strengths.
- 2. Cluster the data.
- 3. Draw inferences and identify problems.
- 4. Propose possible nursing diagnoses.
- 5. Check for defining characteristics of those diagnoses.
- 6. Confirm or rule out nursing diagnoses.
- 7. Document conclusions.