Nursing 204 Exam 2 notes (Well-enlightened)

when does the assessment process begin? what is the next step? correct answers - initial meeting between nurse and client/ family - obtain information about the client's current and past problems in addition to your interview, assessment includes information you obtain from: correct answers existing records, past diagnostic testing, information from family, and in some instances, contact with previous health care providers, schools, or other referral sources subjective data correct answers (stated) - client's perception of data and what client or family says about the data objective data correct answers (observed) - data directly observed or verified through physical exams or tests - document specific, measurable terms nursing diagnosis correct answers - a comprehensive biopsychosocial statement that captures the essence of the client's health care needs/ problems - describes the client's human responses to health issues and medical diagnoses types of nursing diagnosis correct answers problem- focused risk and high- risk possible health promotion syndrome problem- focused nursing diagnosis (4 components) correct answers - human response to health conditions/ life processes that can exist in an individual, family, or community - supported by defining characteristics that cluster in patterns of related cues or inferences components: label, definition, defining characteristics, and related factors label for problem- focused ND correct answers the label should be clear, concise terms that convey the meaning of the diagnosis definition for problem- focused ND correct answers - the definition should add clarity to the diagnostic label - it should also help to differentiate a particular diagnosis from similar diagnosis defining characteristics of problem- focused ND correct answers - signs and symptoms that, when seen together, represent the nursing diagnosis (major and minor) related factors of problem- focused ND (4 categories) correct answers - related factors are contributing factors that have influenced the change in health status 4 categories: