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Sources of assessment - ANSWER ✔✔Comprehensive Initial
assessment: performed shortly after a patient is admitted to a health
care agency or service.
focused assessment: the nurse gathers data about specific problems
that have already been identified. Signs and symptoms, when did they
start, what makes symptoms better or worse, are you taking any
remedies for your symptoms, were you doing anything out of the norm
when they started
,Emergency assessment: identifies life threatening problems concerning
physiological or phycological crisis
Time-Lapsed assessment: is scheduled to compare a patients current
status to the baseline data obtained earlier
Quick Priority: short, focused, prioritized assessments nurses do to gain
the most important information they need to have first
Assessment includes the following: - ANSWER ✔✔Systematic
collection of information about the client
From data sources; physical assessment, vital signs, environmental and
individual safety
From the client
From the family
From other health care professionals
Categorization of information (organizing)
Verification of information
Analysis of information as a basis for nursing diagnoses
,What is clustering - ANSWER ✔✔clustering related data and
identifying patters
Recognize Gordon's Functional Health Pattern classifications (11
general ones) - ANSWER ✔✔1. Health Perception/Management
2. Activity & Exercise
3. Nutrition
4. Elimination
5. Sleep-Rest
6. Cognitive-perceptual
7. Self perception-self concept
8. Role-relationship
9. Sexuality-reproductive
10. Coping-stress tolerance
11. Values-beliefs
Objective data - ANSWER ✔✔are observable and measurable data
that can be seen, heard, felt, or measured by someone other than the
person experiencing them
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, Subjective data - ANSWER ✔✔are information perceived only by the
effected person; these data cannot be perceived or verified by another
person
Identify the primary source for assessment data - ANSWER
✔✔***The PATIENT is your primary source of data All other data is
considered secondary
What is needed throughout the nursing process - ANSWER
✔✔Reassessment!!
As the client status changes you must go back and
REASSESS! You should be assessing your patients CONTINUOUSLY,
throughout your shift
**Nurses are responsible for alerting the appropriate health care
professional whenever assessment data differ significantly from the
patient's baseline, indicating a potentially serious problem. Interventions
for which the nurse may be legally responsible include increasing the
frequency of assessments and initiating necessary changes in the
treatment regimen.