(Modules 1-3) Exam
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,What is an assessment?
-A data collection process
-A continuous process
-A method to establish a baseline
What is primary subjective data? Give an example.
Client reports feelings/thoughts
Ex. "I have a headache"
What is secondary subjective data? Give an example.
Anyone, other than the client, reports feelings/thoughts.
Ex. Spouse states, "She complained of pain in her abdomen this morning."
What is primary objective data? Give an example.
Nurse reports seeing, feeling, smelling, or hearing. (DO NOT
taste). Ex. "I can see redness and swelling of her right lower
extremity."
What is secondary objective data? Give an example.
Anyone, other than the nurse, reports seeing, feeling, smelling, or hearing. (DO
NOT taste).
Ex. AP states, "Her urine smells odorous."
, What is a comprehensive assessment?
Consists of a complete nursing history and physical examination.
What is a focused assessment?
Based around the patients immediate problems.
What is the nursing process?
Assessment
Diagnosis
Planning
Implementation
Evaluation
(ADPIE)
What is the "A" in the nursing process?
Assessment - gather information and review the patients history
What is the "D" in the nursing process?
Diagnose - identify problem list
What is the "P" in the nursing process?
Plan - develop SMART goals, desired outcomes, and action plans
What is the "I" in the nursing process?
Implementation - perform nursing actions