Define Assessment - answer✔Collects comprehensive data pertinent to the patient's health and/or
situation.
- info medical personnel can look at
- begins the moment you walk through the door
Can the RN provide subjective information about patient? - answer✔NO! Only the patient can
give subjective info.
OBJECTIVE info is what the RN sees, hears, or smells
What is the Diagnosis phase? - answer✔Analyze the assessment and make a clinical judgement
related to an ACTUAL or POTENTIAL health problem.
** Nurses have to be aware of potential risks based on health problems.
** Also collaborate with other specialists to manage the problem(s)
What are the three phases of a Nursing Diagnosis? - answer✔First info → Related to → as
evidence by
WHAT is the problem?
WHY is it a problem?
WHAT is the evidence of that problem?
Ex:
"Acute pain → related to surgical incision → as evidence by patient report (or as evidence by
crying)"
What are the OUTCOMES IDENTIFICATION? - answer✔This is the statement of how a
patient's status will change once interventions have been successfully instituted
FEEDBACK in communication process - answer✔The message that the receiver returns. This
indicates if receiver understood meaning of message. Sender can evaluate effectiveness of
communication.
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