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