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Health Assessment Study Guide
What are the 6 steps of the nursing process?
1. Assessment
2. Diagnosis
3. Outcome
4. Planning
5. Implementation
6. Evaluation
Assessment Definition (nursing process)
1. Collect data
2. Use evidence-based assessment techniques
3. Document relevant data
Diagnosis Definition (nursing process)
1. Compare clinical findings with normal and abnormal variation and
developmental events
2. Interpret data-- make & test hypotheses
3. Validate diagnoses
4. document diagnoses
Outcome Identification Definition (nursing process)
1. Identify expected outcomes
2. Individualize to the person
3. Culturally appropriate
4. realistic and measurable
5. include a timeline
Planning Definition (nursing process)
1. ESTABLISH PRIORITIES
2. Develop Outcomes
3. Set timelines for outcomes
4. IDENTIFY interventions
, 2
5. Integrate evidence-based trends and research
6. Document plan of care
Implementation Definition (nursing process)
1. Implement in a safe and timely manner
2. Use evidence-based interventions
3. Collaborate with colleagues
4. use community resources
5. coordinate care delivery
6. provide health teaching and health promotion
7. document implementation and any modifications.
Evaluation Definition (nursing process)
1. Progress toward outcomes
2. conduct systematic, ongoing, criterion-based evaluation.
3. Include patient and significant others
4. use ongoing assessment to revise diagnoses, outcomes, plan
5. distribute results to patient and family
Acute pain
1. Is short term and self-limiting, often follows a predictable trajectory, and
dissipates after an injury heals.
2. Self-protective purpose; it warns the individual of actual or threatened tissue
damage.
Chronic Pain
1. Over 6 months in duration
2. Adaptive responses
Phantom pain
1. Pain where limb used to exist
Malignant pain Vs nonmalignant pain
Health Assessment Study Guide
What are the 6 steps of the nursing process?
1. Assessment
2. Diagnosis
3. Outcome
4. Planning
5. Implementation
6. Evaluation
Assessment Definition (nursing process)
1. Collect data
2. Use evidence-based assessment techniques
3. Document relevant data
Diagnosis Definition (nursing process)
1. Compare clinical findings with normal and abnormal variation and
developmental events
2. Interpret data-- make & test hypotheses
3. Validate diagnoses
4. document diagnoses
Outcome Identification Definition (nursing process)
1. Identify expected outcomes
2. Individualize to the person
3. Culturally appropriate
4. realistic and measurable
5. include a timeline
Planning Definition (nursing process)
1. ESTABLISH PRIORITIES
2. Develop Outcomes
3. Set timelines for outcomes
4. IDENTIFY interventions
, 2
5. Integrate evidence-based trends and research
6. Document plan of care
Implementation Definition (nursing process)
1. Implement in a safe and timely manner
2. Use evidence-based interventions
3. Collaborate with colleagues
4. use community resources
5. coordinate care delivery
6. provide health teaching and health promotion
7. document implementation and any modifications.
Evaluation Definition (nursing process)
1. Progress toward outcomes
2. conduct systematic, ongoing, criterion-based evaluation.
3. Include patient and significant others
4. use ongoing assessment to revise diagnoses, outcomes, plan
5. distribute results to patient and family
Acute pain
1. Is short term and self-limiting, often follows a predictable trajectory, and
dissipates after an injury heals.
2. Self-protective purpose; it warns the individual of actual or threatened tissue
damage.
Chronic Pain
1. Over 6 months in duration
2. Adaptive responses
Phantom pain
1. Pain where limb used to exist
Malignant pain Vs nonmalignant pain
