Common Nursing Definition Themes - ANSWER •Health Promotion
•Health maintenance
•Restoration
•Support of the dying
Nursing Process - ANSWER •Assessment
•Diagnosis
•Outcome identification & planning
•Implementation
•Evaluation
•Provides the basis for critical thinking in nursing
•Each step is dependent on the accuracy of the preceding step
•ADPIE!
Nursing Process- Nurse Importance - ANSWER •Accredited schools all teach
it so it's consistent and systematic
•State boards are organized around it
•Provides goal-oriented care
•Analysis of outcomes results in greater skill & professional knowledge
•Speeds nursing care so LOS is reduced
•Enhances team cooperation/collaboration
•Avoids omissions, mistakes, and duplication of effort
,Nursing Process- Client Benefit - ANSWER •Receives specific care
•Continuity of care
•Allows for client involvement
•Client satisfaction is promoted
Assessment - ANSWER •Focused data collection
•Validation of data
•Data analysis
•JUDGEMENT or interpretation
•Recording of the data
JCAHO Assessment Guidelines - ANSWER •Every client must have a
documented nursing assessment
•Relevant to client needs
•Collected from a variety of sources
•Collected using appropriate techniques
•Collected in a systemic manner
•Documented in a usable format
Purpose of Assessment - ANSWER •To establish a database
•To determine functional abilities/presence of dysfunction
•To identify strengths
•To form therapeutic relationship
•To identify actual or potential health problems
Types of Assessments - ANSWER •Initial/comprehensive assessment
, •Focused assessment
•Ongoing assessment
Subjective Data - ANSWER •From the client's POV
•Includes feelings, perceptions and concerns symptoms
•Cannot be readily observed by another
Objective Data - ANSWER •Observable & measured
•Obtained throughout observation & standard assessment technique
•Obtained through lab & diagnostic testing
•Signs that can be seen, heard or felt by someone other than the person
experiencing them
Primary Source - ANSWER •The patient for subjective & objective data
Secondary Source - ANSWER •Any source other than the patient or client
•Significant others, patient chart, medical records, test results, other care
providers, paramedics, police officers, first responders, literature
Data Verification - ANSWER •To make sure information is factual & complete
•Recheck your own data if in question
•Compare your subjective & objective data for congruency
•Clarify patient & family statements
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