an identification by a nurse of the needs, preferences, and abilities of a patient. Assessment includes an interview with and observation of a patient by the nurse and considers the symptoms and signs of the condition, the patient's verbal and nonverbal communication, the patient's medical and social history, and any other information available. Among the physical aspects assessed are vital signs, skin color and condition, motor and sensory nerve function, nutrition, rest, sleep, activity, elimination, and consciousness. Assessment is extremely important because it provides the scientific basis for a complete nursing care plan. Show a statement of a health problem or of a potential problem in the client's health status that a nurse is licensed and competent to treat. Four steps are required in the formulation of a nursing diagnosis. A data base is established by collecting information from all available sources, including interviews with the client and the client's family, a review of any existing records of the client's health, observation of the client's response to any alterations in health status, a physical assessment, and a conference or consultation with others concerned in the client's care. The data base is continually updated. The second step includes analysis of the client's responses to the problems, healthy or unhealthy, and classification of those responses as psychologic, physiologic, spiritual, or sociologic. The third step is the organization of the data so that a tentative diagnostic statement can be made that summarizes the pattern of problems discovered. The last step is confirmation of the sufficiency and accuracy of the data base by evaluation of the appropriateness of the diagnosis to nursing intervention and by the assurance that, given the same information, most other qualified practitioners would arrive at the same nursing diagnosis. In use, each diagnostic category has three parts: the term that concisely describes the problem, the probable cause of the problem, and the defining characteristics of the problem. Sets with similar termsRecommended textbook solutions
 Pharmacology and the Nursing Process7th EditionJulie S Snyder, Linda Lilley, Shelly Collins 382 solutions
Clinical Reasoning Cases in Nursing7th EditionJulie S Snyder, Mariann M Harding 2,512 solutions
The Human Body in Health and Disease7th EditionGary A. Thibodeau, Kevin T. Patton 1,505 solutions
Introduction to Global Health2nd EditionKathryn H Jacobsen 116 solutions Recommended textbook solutions
Clinical Reasoning Cases in Nursing7th EditionJulie S Snyder, Mariann M Harding 2,512 solutions
Pharmacology and the Nursing Process7th EditionJulie S Snyder, Linda Lilley, Shelly Collins 382 solutions
The Human Body in Health and Disease7th EditionGary A. Thibodeau, Kevin T. Patton 1,505 solutions
Epidemiology for Public Health Practice5th EditionRobert H Friis, Thomas Sellers 124 solutions What are possible sources of information to use in the assessment step of the nursing process?The primary source of data collection during the nursing assessment is the patient. Other sources include family, friends, caregivers, and other members of the healthcare team. Data are also collected from laboratory or diagnostic reports, the patient's medical records, and the nurse's observations.
What are the sources of information in nursing?Most information sources in the nursing literature are medical journal articles followed by articles from nursing and other journals. This is particularly true among articles in clinical specialty journals. About 10% of the citations in articles in nursing journals are to gray literature.
What are the sources of data in health assessment?The main sources of health statistics are surveys, administrative and medical records, claims data, vital records, surveillance, disease registries, and peer-reviewed literature.
Which primary source of information would the nurse use when completing a patient's assessment quizlet?The client is the primary, and usually best, source of information when doing an assessment. The medical record may also provide information, but only if the client has been at the health care facility before; even then, the client is likely to have more current information than the medical record.
|
What are possible sources of information to use in the assessment step of the nursing process quizlet?
zusammenhängende Posts
Urheberrechte © © 2024 IlerngutCOM Inc.
