What is assessment in nursing?
The collection of subjective and objective data about a patient’s health.
What is subjective data?
Information provided by the affected individual (patient’s perspective).
What is objective data?
Information obtained by the health care provider through observation, inspection, percussion, palpation, and auscultation.
What makes up the patient database?
Subjective data, objective data, medical record, and laboratory studies.
What is the purpose of assessment?
To make a judgment or diagnosis.
After data collection, what should nurses do?
Cluster or group related data and validate it to ensure accuracy.
What are the six phases of the nursing process?
Assessment, diagnosis, outcome identification, planning, implementation, and evaluation.
How does the novice nurse apply the nursing process?
With no prior experience in specific populations, they use rules to guide performance and build competency.
How does the proficient nurse apply the nursing process?
Sees the patient’s situation as a whole, recognizes patterns, and acts without consciously labeling them.
How does the expert nurse apply the nursing process?
Uses intuition, quickly grasps the situation, and zeros in on the accurate solution.
What is critical thinking in nursing?
Sound diagnostic reasoning and clinical judgment, involving identifying relevant information, gathering cues, completing assessments, and setting priorities.
What are first-level priority problems?
Emergent, life-threatening, and immediate (e.g., airway, breathing).
What are second-level priority problems?
Require prompt intervention to prevent further deterioration (e.g., mental status changes, acute pain, abnormal labs).
What are third-level priority problems?
Important to health but less urgent, addressed after higher priorities (e.g., lack of knowledge, family coping).
What are collaborative problems?
Physiologic conditions that require multidisciplinary treatment approaches.
What is evidence-based practice (EBP)?
A systematic approach using research evidence, clinical expertise, clinician knowledge, and patient preferences/values to guide care.
What are the four types of patient databases?
Complete, focused, follow-up, and emergency.
What is a complete (total health) database?
Includes a full health history and physical exam, providing initial diagnoses.
What is a focused (problem-centered) database?
Targeted to a limited or short-term problem; smaller in scope than a complete database.
What is a follow-up database?
Evaluates the status of identified problems at intervals to monitor short-term and chronic conditions.
What is an emergency database?
Rapid collection of crucial data while performing lifesaving measures.
