Chapter5 Assmt, Nursing, Diagnosis, and Planning
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consists of gathering info about patients and their needs using a variety of methods.
pieces of info on a specific topic.
all the info gathered about a patient and documented.
often asked to assist with this task and participates in carrying out the plan by continuing to collect data.
Focused assessment is
concerned with one very specific problem.
Subjective data is
data obtained from the patient verbally.
Subjective data examples are
- 1. I have a headache
- 2. I am nauseated
- 3. The sharp pain is in my hip
- 4. Ive been feeling really blue lately
- 5. Ive been lonely since my husband died
Objective data is
information obtained through the senses and hands-on physical examination.
Objective data examples are
- 1. Temperature 101.4 F
- 2. 135 mL emesis at 0820
- 3. Bruise on the right hip
- 4. Eyes downcast, flat affect
- 5. Only one visitor seen in room all day
Interview consists of 3 stages
- 1. the opening, when rapport is established with the patient
- 2. the body of the interview, when the necessary questions are presented
- 3. the closing segment of the interview. discuss purpose of the interview
an ongoing process, you will continue to gather data each time there is an encounter.
When interviewing an elderly person,
allow more time because the person will prob have a more extensive history and may take a little longer to recall the needed info.
Chart review is
a data collection tool that assists in obtaining the info needed to intelligently interview the pt or to prepare adequately for the days pt assignment.
Assessment in Long-Term Care
- 1. for medicare pts every 90 days
- 2. functional assessment is performed ADL's
- 3. personal preference routine
Assessment in Home Health Care
- 1. initial assessment performed at home by RN
- 2. lvn/lpn will assist in daily assessments and maintain necessary documents
pieces of data or information that influence decisions.
conclusions made based on observed data.
indicates the patient's actual health status or the risk of problem developing, the causative or related factors, and specific defining characteristics(signs and symptoms)
Medical diagnosis is
never included in the construction of the nursing diagnosis.
Etiologic factors are
the cause of the problem.
abnormalities that can be verified by repeat examinations and are objective data.
data the patient has said are occuring that cannot be verified by examination. symptoms are subjective data.
Defining characteristics are
those characteristics (signs and symptoms) that must be present for a particular nursing diagnosis to be appropriate for that person.
always comes first.
for basic survival take precedence.
Every nurse must
attempt to look at each pt holistically, keeping psychosocial needs in mind while working on physical problems.
a broad idea of what is to be achieved through nursing intervention.
Short term goals are
those that are achievable within 7 to 10 days or before discharge.
Long term goals
make take many weeks or months achieve. often relate to rehab.
Expected outcome is
a specific statement of the goal the patient is expected to achieve as a result of nursing intervention.
Expected outcome should be
realistic and attainable and should have a defined a time line.
Nursing Outcomes Classification is to
- 1. identify, label, validate, and classify patient outcomes and indicators
- 2. field test the classfications for validations
- 3. define and test the measurement procedures to determine if the outcomes are met by the interventions that have been implemented.
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