RLE 1

• Nursing health assessment focuses on both health history and physical examination, is used to evaluate the overall health status of an individual, and involves a systematic data gathering that provides pertinent information to facilitate a plan to deliver the quality nursing care for the patient.
• Nursing assessment, a part of the Nursing Process (ADPIE), is the systematic and continuous collection, organization, validation and documentation of information.
• Nursing assessment is a deliberate and interactive process that underpins every aspect of nursing care.
• Nursing assessment involves the gathering of data about the patient, considering the physical, emotional, mental, socio-cultural and spiritual factors that may affect his/ her health status.
• The Nursing Process (ADPIE) includes nursing assessment, nursing diagnosis, nursing intervention, and nursing evaluation.
• An assessment expected for a client in a medical floor, such as “I cannot breathe!” or Oxygen Saturation of 92%, is considered objective data.
• Continuous assessment of the patient’s health status accompanied by monitoring and observation of specific problems identified in a mini, initial comprehensive or focused assessment is known as problem-oriented assessment.
• An assessment of a patient’s wound, such as a 1 inch cut on the left pinky finger, 1 cm deep, is considered objective data.
• An assessment utilized in the Emergency room for a victim of a trauma with multiple injuries from a car crash is an Emergency assessment.
• A quick visual and physical assessment of the patient, considering patient’s ABC (airway, breathing and circulation), then assessing mental status, overall appearance, level of consciousness and vital signs before focusing on the patient’s main problem is known as a quick assessment.
• An assessment utilized by a Neuro-ICU nurse caring for an 18-year-old female patient who had a bad car crash and was admitted from the trauma bay is a Problem-oriented assessment.
• An assessment of a specific condition, problem, identified risks or assessment of care; for example, continence assessment, nutritional assessment, neurological assessment following a head injury, assessment for day care, outpatient consultation for a specific condition is known as the Mini assessment.
• An assessment utilized by a nurse in the surgical ward caring for an elderly client who had left knee replacement and will be discharged directly to an Aged care facility today is an Ongoing assessment.
• Nursing assessment is the first phase of the Nursing Process (ADPIE).
• Nursing assessment involves a systematic data gathering that provides pertinent information to facilitate a plan to deliver the quality nursing care for the patient.
• The role of the nurse in health assessment is to utilize all the findings to decide which areas the patient is in need of the most care and which levels of prevention are necessary.
• The phases of the Nursing Process (ADPIE) include nursing assessment, nursing diagnosis, nursing intervention, and nursing evaluation.
• A pain scale which is rated as 8/10 is objective data.
• Types of patient assessment include overall assessment, health assessment, initial comprehensive assessment, ongoing assessment, focused assessment, and emergency assessment, also known as the admission assessment.
• Nursing planning involves devising the best course of action to address the patient’s diagnoses.
• Nurses are able to detect through health assessment areas in need of health adjustments, areas that need continuous care, areas that need in-hospital care, areas that need referral to a specialist, and areas that need education for the patient’s family.
• An ongoing assessment is a type of assessment that takes place on a regular basis.
• Primary sources of data include the patient, family members, friends and significant others, and the patient’s record or chart.
• Objective data can be observed and measured.
• Nursing evaluation is a continuing process that determines if the goals / outcomes have been attained.
• Subjective data can be described only by the patient / the person experiencing it.
• Using both verbal and nonverbal clues given by the patient, the nurse constantly assesses the patient.
• Observation uses senses (vision, hearing, touch, smell) and units of measure (mmHg, degrees C) to gather data.
• A focused assessment is a type of assessment that takes place when a specific problem arises.
• An emergency assessment, also known as the admission assessment, is a type of assessment that takes place when a patient is admitted to a hospital or healthcare agency.
• Interview is a planned, purposeful conversation used for health history and admission of a patient to a healthcare facility.
• An overall assessment of a patient utilizes findings and identifies in what areas the patient needs the most care.
• Nursing implementation involves the development of the steps to execute the plan.
• Nursing diagnosis has a nursing focus and is based on real or potential health problems or human responses to health problems.
• During nursing planning, the nurse and the patient select goals for each diagnosis in order to alleviate, decrease, or prevent the problems addressed in the nursing diagnosis.
• Secondary sources of data include health team members.
• An in-depth assessment of the patient’s health status, physical examination, risk factors, psychological and social aspects of the patient’s health that usually takes place on admission or transfer to a hospital or healthcare agency is known as an initial comprehensive assessment.