Fundamentals NURS 305 Exam 1 study guide

Fundamentals NURS 305 Exam 1 study guide CHAPTER 16 ASSESSMENT  Subjective Data o Information gathered from patient statements; the patients feelings and perceptions not verifiable except by inference  Objective Data o Information that can be observed by others; free of feelings, perceptions and prejudice  Comprehensive assessment o Problem oriented approach o Strengths and problems of the patient o Assessment moves from generic to specific o Use of a structured database format based on an accepted theoretical framework or practice standard (ex: gordon’s model of functional health problems) o Broad assessment of health history and all body systems  Problem-oriented assessment o Focus on the patients presenting situation and begin with problematic areas (ex: incisional pain or limited understanding of postop recovery) o Ask follow up questions to clarify and expand your assessment to understand the full nature of the problem o Later, a physical exam confirms your observations  Focused assessment o Assessment of a particular body system or body process  Nursing assessment o The purpose is to establish a databases about the patient’s perceived needs, health problems and responses to these problems