1. Data documentation
    • last component of assessment
    • legal and professional responsibility
    • requires accurate and approved terminology and abbreviations
  2. analysis
    • recognize a pattern or trend
    • compare with normal standards
    • make a reasoned conclusion
    • examine ideas, and identify any gaps in the database
  3. Interpretation
    • ability to categorize data, decode relevant info
    • ability to clarify meaning
  4. Nursing health history
    • data about the client's current level of wellness
    • observation of client behavior
    • diagnostic and lab data
    • interpreting assessment data and making nursing judgments
  5. Interview and Nursing Health History
    • organized conversation with client
    • orientation phase
    • working phase-gather data
    • termination- verbal and non verbal
  6. Critial thinking approach
    • 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
  7. Critical thinking and nursing assessment
    • Standards
    • Experience
    • Attitudes
    • Knowledge
  8. 5 step nursing process
    • Assess
    • Diagnose
    • Plan
    • Implement
    • Evaluate
  9. Nursing Process
    a professional nurse's approach to identifying, diagnosing and treating human responses to health and illness
Card Set