assessment correct answers collection of data (patient) related to an individuals health
first step in the nursing process and every approach to clinical reasoning
an ongoing process, not just one time at the beginning of care
the nursing process correct answers start with assessment, then nursing diagnosis, what is the
patient outcome that I want, plan how to get that outcome, are you going to do it
(implementation), evaluation
if it didn't work go through the cycle again
assessment correct answers collect data: review of the clinical record, health history, physical
examination, functional assessment, risk assessment, review of the literature
use evidence-based assessment techniques
document relevant data
collect subjective (what patient says about himself/herself during history taking) and objective
data (nurse observations: inspection, percussion, palpation, auscultation--in that order)
interpret data correct answers compare findings (normal/abnormal)
identify nursing diagnosis
,outcome identification correct answers identify expected outcomes/findings
individualize to patient
ensure outcomes: realistic, measurable, time frame
planning correct answers establish priorities
develop outcomes
identify interventions
document plan of care
set times for outcomes
integrate evidence-based trends and research
implementation correct answers implement interventions in a safe and timely manner
use evidence-based interventions
collaboration with colleagues
use community resources
coordinate care delivery
,provide health teaching and health promotion
document care/implementation and any modification
evaluation correct answers compare established outcomes with actual outcomes
progress toward outcomes
conduct systematic, ongoing criterion-based evaluation
include patient and significant others
use ongoing assessment to revise diagnoses, outcomes, pain
disseminate results to patient and family
identify any roadblocks
modify plan
document evaluation of plan of care
evidence-based practice (EBP) correct answers "Systematic approach to practice that emphasizes
the use of best evidence in combination with the clinician's experience, as well as the patient
preferences and values, to make decisions about care and treatment."
Accurate assessment guides you through application of the nursing process as you provide care
, Inaccurate assessment could lead to an incorrect nursing diagnosis, interventions, or outcomes
(your plan may be ineffective/inaccurate, incomplete assessments could lead to selection of
inappropriate interventions) correct answers Why is thorough assessment necessary?
comprehensive (admission assessment) correct answers includes health history and physical
exam
enables practitioner to have complete picture of the patients health status
episodic/focused (shift assessment) correct answers when you're leaving and someone is taking
your shift
emergency assessment correct answers focuses on "ABC'c" (airway, breathing, circulation)
follow-up assessment correct answers example: pain score after treatment of pain (after
treatment)
subjective and objective data correct answers What are the two types of patient data?
subjective data correct answers What the individual tells you in the interview
What the person says
Information from family members
Examples: family history, past medical history, cultural & spiritual, development, functional,
mental status, pain, nutritional