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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.
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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
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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
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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
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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
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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.
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