By
Essay Doctor
‐
‐
Questions and Answers
, What are the steps of the nursing process? ADPIE A=assessment D=diagnosis P=planning I=implementation E=evaluation
How does the nurse obtain assessment info? 1- initial (or admission assessment) 2- focused assessment 3- emergency assesment
past medical hx - family hx - reason for admission - current meds - previous
hospitalizations & surgeries - psychosocial assessment - nutrition - complete physical
How does the nurse obtain assessment info? assessment
Collects data about a problem that has already been identified. This type of
assessment determines whether the problem still exists, or any changes.
focused assessment
‐ What are your symptoms?
‐ When did they start?
‐ What activity were you doing ?
focused assessment questions
‐ What makes it better or worse?
‐ What are you doing to relieve the symptom?
Performed to identify a life‐threatening problem (choking, stab wound, heart attack).
Emergency assessment
subjective data Information verbalized or stated by the client.
‐ Observable and measurable information.
objective data ‐ Remember to include your senses: smell, hearing, touch and sight.
sign An objective finding perceived by the examiner ex. (fever, rash, etc.)
Subjective findings verbalized or stated by the client ex. ("I have a headache" " I feel sick in
symptom my stomach.")
signs are objective
symptoms are subjective
2 sources of data primary & 2ndary
primary source of data ‐Information obtained from the patient (only)
‐ Family members
‐ Significant others
secondary sources of data ‐ Past & current health records, laboratory tests,diagnostic procedures, consultations from
other healthcare professionals.
VALIDATE
‐Confirm and verify the information.
collect the data then BLANK the data
‐ Keep it free from errors, bias, or misinterpretation.
Data is 1,2,3 collected, validated, then clustered
defining characteristics which are specific assessment findings that support a nursing
clustering of data often contains diagnosis.
critical thinking is used to analyze and synthesize the information that is collected. The
data is then put into specific clusters that describe a specific client problem.
during the clustering of data what is used
identify sources of data for obtaining subjective & objective, primary & secondary, people, healthcare professionals, medical chart,
information from the client test & lab results etc