Nursing Process Correct Answer-a scientific method designed to deliver
the very best in patient care
1. assessment (MOST CRITICAL)
2. diagnosis
3. planning
4. implementation
5. evaluation
initial comprehensive assessment Correct Answer-Collection of
subjective data about the client's perception of health of all body parts or
systems, past medical history, family history, and lifestyle and health
practices.
ongoing or partial assessment Correct Answer-Data collection that
occurs after the comprehensive database is established
focused/problem-oriented assessment Correct Answer-thorough
assessment of a particular client problem, which does not cover areas not
related to the problem
emergency assessment Correct Answer-Very rapid assessment
performed in life-threatening situations
, open-ended forms (traditional) Correct Answer--calls for narrative
description of problem and listing of topics
-provides lines for comments
-individualizes information
-provides "total picture", including specific complaints and symptoms in
the client's own words
-increases risk of failing to ask a pertinent question because questions
are not standardized
-requires a lot of time to complete the database
Cued or checklist forms Correct Answer--standardized data collection
-lists(categorizes) information that alerts the nurse to specific problems
or symptoms assessed for each client
-usually includes a comment section after each category to allow for
individualization
-prevents missed questions
-promotes easy, rapid documentation
-makes documentation somewhat like data entry because it requires
nurse to place checkmarks in boxes instead of writing narrative
-poses chance that a significant piece of data may be missed because the
checklist does not include the area of concern
integrated cued checklists Correct Answer--combines assessment data
with identified nursing diagnosis