NSG 100 Exam V1
• How does assessment manage nursing care: -determine current and ongoinghealth status
-predicts patient's health risks
-identify appropriate health promotiing activities
-carried through all phases of nursing process
-focused on pt's response to a health problem
• Assessment includes: -is holistic
-physio, psych, socio, spiritual, economic, lifestyle
• Two steps of nursing assessment: 1. data collection and verification
2. data analysis (foundation for second step-diagnosis)
• primary source: client, family, significant others
• secondary source: medical records, family and significant others, other HCP
• steps in analyzing assessment data: -comparing data against standards toidentify
significant cues
-clustering cues to generate tentative hypothesis
-identifying gaps and inconsistencies
• subjective data: -what client says
-cannot be observed directly
-symptoms (pain, dizzy, anxious)
-client health history
• objective data: -direct measurements or observation (vital signs)
-can be observed(posture, pallor, crying)
-signs (describes characteristics of disease or dysfunction)
• problems related to data collection: -inappropriate organization of database
-omission of pertinent data
-inclusion of irrelevant or duplicate data, erroneous or misinterpreted data
-failure to est rapport
-recording interpretation of data rather than observed behavior
-failure to update the database
, • parts of inital assessment: 1. interview and health history
2. physical exam
• nursing assessment: -first step in nursing process
-est a thorough database
-thorough and accurate equals appropriate diagnosis
• Nursing Diagnosis: -clinical judgement
-provides the basis for selection of nursing interventions to achieve outcomes forwhich the
nurse is accountable
• Nursing diagnosis reasoning process: -review assessment data
-cluster the data
-data interpretation and analysis
-select diagnositc label
-determine related factors and defining characteristics
• data clustering: -set of s/s gathered during assessment
-patterns of data with defining characteristics
• NANDA-I: -provides a common language
-comm what nurses do
-distinguishes the role from other HCP
-assists nurses to focus on scope of practice
-fosters development of knowledge
• components of a nursing diagnosis (2 part format): 1. Diagnostic label
2. related factor (r/t)- etiology
Acute pain related to uterine contractions.
• critical thinking: the deliberate nonlinear process of collecting, interpreting, an-alyzing,
drawing conclusions about, presenting and evaluating information that is both factual and
belief-based
• clinical decision making: a process NURSE uses to evaluate and select thebest actions to
meet desired goals
• How does assessment manage nursing care: -determine current and ongoinghealth status
-predicts patient's health risks
-identify appropriate health promotiing activities
-carried through all phases of nursing process
-focused on pt's response to a health problem
• Assessment includes: -is holistic
-physio, psych, socio, spiritual, economic, lifestyle
• Two steps of nursing assessment: 1. data collection and verification
2. data analysis (foundation for second step-diagnosis)
• primary source: client, family, significant others
• secondary source: medical records, family and significant others, other HCP
• steps in analyzing assessment data: -comparing data against standards toidentify
significant cues
-clustering cues to generate tentative hypothesis
-identifying gaps and inconsistencies
• subjective data: -what client says
-cannot be observed directly
-symptoms (pain, dizzy, anxious)
-client health history
• objective data: -direct measurements or observation (vital signs)
-can be observed(posture, pallor, crying)
-signs (describes characteristics of disease or dysfunction)
• problems related to data collection: -inappropriate organization of database
-omission of pertinent data
-inclusion of irrelevant or duplicate data, erroneous or misinterpreted data
-failure to est rapport
-recording interpretation of data rather than observed behavior
-failure to update the database
, • parts of inital assessment: 1. interview and health history
2. physical exam
• nursing assessment: -first step in nursing process
-est a thorough database
-thorough and accurate equals appropriate diagnosis
• Nursing Diagnosis: -clinical judgement
-provides the basis for selection of nursing interventions to achieve outcomes forwhich the
nurse is accountable
• Nursing diagnosis reasoning process: -review assessment data
-cluster the data
-data interpretation and analysis
-select diagnositc label
-determine related factors and defining characteristics
• data clustering: -set of s/s gathered during assessment
-patterns of data with defining characteristics
• NANDA-I: -provides a common language
-comm what nurses do
-distinguishes the role from other HCP
-assists nurses to focus on scope of practice
-fosters development of knowledge
• components of a nursing diagnosis (2 part format): 1. Diagnostic label
2. related factor (r/t)- etiology
Acute pain related to uterine contractions.
• critical thinking: the deliberate nonlinear process of collecting, interpreting, an-alyzing,
drawing conclusions about, presenting and evaluating information that is both factual and
belief-based
• clinical decision making: a process NURSE uses to evaluate and select thebest actions to
meet desired goals
