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Terms in this set (82)
Health is a state of complete physical, mental, and
social well-being and not merely the absence of
disease or infirmary (WHO, 1948)
Health is the balance of the person and the outside
Define Health world. It is a complex, interrelated complex. (Jarvis)
Health: a state of optimal functioning or well-being.
Holistic model of health - mind, body, and spirit are
interdependent and function as a whole.
Assessment is the collection of data about the
individual's health.
A systemic, deliberate, interactive process by which
Define health assessment
nurses use critical thinking to collect, validate,
and its components.
analyze and synthesize the collected information in
order to make judgement about the health status
and life processes of individuals, families, and
communities.
, Subjective - what the patient says about himself or
herself during history taking
e.g. "I'm nauseous"
Discuss subjective and Objective - what you as the healthcare professional
objective data and observe when inspecting, percussing, palpating,
recognize examples of and auscultating patient during physical
both. examination.
e.g. Vital signs, excessive sweating, bruising
Together with the patient's record and lab studies -
form the database.
Assessment
Diagnosis
What are the steps of the
Planning
nursing process?
Implementation
Evaluation
Systematically collect patient data
Describe the assessment
step of the nursing Use EBP techniques
process
Document relevant data
Compare clinical findings w/ normal/abnormal
variation and developmental events
Describe the diagnosis
Interpret data
step of the nursing
process
Validate diagnosis
Document diagnosis
, Establish priorities
Develop outcomes (& set timelines)
Describe the planning
step of the nursing Identify interventions
process
Integrate evidence-based trends and research
Document plan of care
Implement in a safe & timely manner
Use evidence-based interventions
Collaborate with colleagues
Describe the
implementation step of Use community resources
the nursing process
Coordinate care delivery
Provide health teaching and health promotion
Document implementation and any modifications
Progress toward outcomes
Conduct systematic, ongoing, criterion-based
evaluation
Describe the evaluation
step of the nursing Include patient and significant others
process
Use ongoing assessment to revise diagnoses,
outcomes, plan
Disseminate results to patient and family