Chapter 1, HA
physiologic status
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's
continuous
Although the assessment phase of the nursing process precedes the other phases, the assessment phase is
includes a brief reassessment of the client's normal body system
An ongoing or partial assessment of a client
Diagnoses
Analysis of subjective and objective data to make a professional nursing judgment
Evaluation
Assessing whether outcome criteria have been met and revising the plan of care if necessary
arrive at conclusions about the client's health
Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the propose of the assessment is to
Implementation
Carrying out the plan of care
Assessment
Collection of subjective and objective data
Planning
Developing a plan of nursing care and outcome criteria
Objective data
Findings directly observed or indirectly observed through measurements (body temp)
Collaborative problems
Physiologic complications that nurses monitor to detect their onset or changes status
Referral problems
Problem that requires the attention or assistance of other health care professionals
Subjective data
Sensations or symptoms that can be verified only by the client (pain)
rapid advances in biomedical knowledge and technology
The depth and scope of nursing assessment has expanded significantly over the past several decades primarily because of
avoid premature judgments about the client
The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should
formulation of nursing diagnoses
The result of a nursing assessment is the
review the client's health care record
To prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first
comprehensive
When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed
Nursing diagnosis
Clinical judgment about individual, family, or community responses to actual or potential health problems and life processes
check for the presence of defining characteristics
To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data. After proposing possible nursing diagnoses, the nurse should next