NUR 2092 Health Assessment Exam 3

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

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