NUR 2092 Health Assessment Exam 1 Review

Steps of Nursing Process – be able to identify and apply Nursing process definition: a systematic, organized method of practicing nursing What are the 6 steps of the nursing process? Assessment Diagnosis Outcome Identification Planning Implementation Evaluation Assessment -collect as much data -physical findings, historical information, verbal and non-verbal observations, medical records, self-care abilities, psycho-social implications In which stage of the nursing process does the nurse review the clinical record and obtain a health history, amongst other tasks? ASSESSMENT Diagnosis -Nursing diagnosis, not medical diagnosis -the only acceptable diagnosis from the North American Nursing Diagnosis Association (NANDA) Identification of a disease or condition by scientific evaluation of physical signs and symptoms Outcome Identification 1) Identify expected outcomes 2) individualize to the person 3) culturally appropriate 4) realistic and measureable 5) include a timeline Planning 1) Establish priorities 2) develop outcomes 3) set timelines for outcomes 4) identify interventions 5) integrate evidence-based trends and research 6) document plan of care Implementation 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 heath teaching and health promotion 7) document implementation and any modification Evaluation -Determination made about the extent to which identified outcomes have been met in the nursing care plan 1) Progress toward outcomes 2) conduct systematic ongoing criterion-based interventions 3) include patient and significant others 4) use ongoing assessment to revise diagnoses, outcomes, plan 5) disseminate results to patient and family 2. Difference between Subjective and Objective Data Collection of Subjective Data (Step 1) Sensation or symptoms (pain/hunger), feelings (happiness/sadness), perceptions, beliefs, ideas, values, & personal info. a. Biographical information (name, age, religion, occupation) b. Physical symptoms related to body (e.g., eyes and ears, abdomen) c. Past health history d. Family history e. Health and lifestyle practices (e.g., health practices that put the client at risk, nutrition, activity, relationships Collection of Objective Data (Step 2) Directly observed by the examiner; Data taken from the client's relatives; Rating a pain scale to measure the intensity of pain. Data include: a. Physical characteristics (e.g. skin color posture) b. Body functions (e.g., heart rate ,respiratory rate) c. Appearance (e.g., dress and hygiene) d. Behavior(e.g., mood, affect) e. Measurements(e.g., blood pressure, temperature, height, weight) f. Results of laboratory testing (e