NUR 2092 Health Assessment Exam 3
- Steps of the Nursing Process
Assessment - gather data Diagnosis - problem Outcome Identification - goals, what we want to happen, expect to happen Planning - treatment plan, intervention Implementation - doing the plan Evaluation - Was it successful, meet the goals
- Define Subjective Data
What patient says about himself or herself during history taking
symptoms
- Define Objective Data
Observed when inspecting, percussing, palpating, and auscultating patient during physical examination
signs
- Factors of Diagnosis
-Cluster of data that seem to be associated in some way.
-Validate data, confirm accuracy -Look for gaps in your information -Interpret data and identify problems -Document the diagnosis
- Factors of Outcome Identification 1 / 3
-Identify expected outcomes related to pa- tient individualization
-Ensure outcomes have the SMART components -Specify short-term and long-term goal measurement criteria
- What does SMART stand for?
Specific, Measurable, Attainable, Realistic, Timely
- Factors of Planning
-Establish priorities based on meeting patients care goals
-Develop outcomes and set time frames for meeting outcomes -Identify relevant interventions and utilize interdisciplinary health care team mem- bers for the patient -Document plan of care
- Factors of Evaluation
-Refer to outcomes
-Evaluate patient's condition and compare actual outcomes to expected outcomes
-If reached outcome
does something need to be done
-If NOT reached
identify reasons for not achieving
-Modify plan if needed 2 / 3
-Document in plan of care
- Evidence-Based Decision Making factors
-Best evidence from clinical review of research literature
-The providers clinical expertise
-Patient's preference and values -Physical examination and assessment of patient
- Focused Database
Problem-centered Used for a limited or short-term problem
Smaller scope and more targeted than the complete database
- Complete Database
Includes a complete health history and full physical examination
Yielding the first diagnosis
- Steps in Priority Problem Levels
- First-level priority
emergent, life threatening, immediate
- Second- level
next in urgency, requires attention to prevent further deterioration
- Third-Level
important to patient's health, but can be addressed after urgent problems
- / 3