Ch.16

• last component of assessment
• legal and professional responsibility
• requires accurate and approved terminology and abbreviations

• recognize a pattern or trend
• compare with normal standards
• make a reasoned conclusion
• examine ideas, and identify any gaps in the database

• ability to categorize data, decode relevant info
• ability to clarify meaning

• data about the client's current level of wellness
• observation of client behavior
• diagnostic and lab data
• interpreting assessment data and making nursing judgments

• organized conversation with client
• orientation phase
• working phase-gather data
• termination- verbal and non verbal

• Collection and verification of data
• Analysis of data
• purpose is to establish a database- which consistis of client's perceived needs health problems and responses to problems

• Standards
• Experience
• Attitudes
• Knowledge

• Assess
• Diagnose
• Plan
• Implement
• Evaluate

a professional nurse's approach to identifying, diagnosing and treating human responses to health and illness