NCMA 111 (CU #1)

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Kath

Cards (18)

Nursing assessment skills are needed for every situation the nurse encounters
A holistic nursing assessment differs from a physical medical assessment
Phases of the nursing process involving assessment by the nurse:
Assessment
Diagnosis
Intervention
Evaluation
Planning
Steps of the nursing process:
Assessment: systematic collection of data, the most important step
Diagnosis: clinical judgment concerning a human response to health conditions/life processes
Intervention: treatment based on clinical judgment to enhance patient outcomes
Evaluation: analysis of the effectiveness of the interventions
Planning: setting goals and outcomes, individualized plan of care
The "analysis phase" of the nursing process involves identifying and prioritizing actual or potential health problems or responses
Objective: behavior or response expected from the patient in a short time, usually within a few hours or less than a week, like resolving a high body temperature or acute pain after surgery
Planning in nursing should be SMART: Specific, Measurable, Attainable, Realistic, and Time-Bound
Intervention in nursing is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes, also known as implementation
Approaches to intervention in nursing:
Direct care: treatment performed through interaction with the patient (e.g., medication administration, vital signs checking)
Indirect care: treatment performed away from a patient but on behalf of the patient or group of patients (e.g., safety and infection control)
Types of nursing interventions:
Independent: actions initiated by the nurse without supervision
Dependent: actions requiring an order from a healthcare provider
Collaborative: interdependent interventions requiring combined knowledge, skills, and expertise of multiple healthcare providers
Evaluation is the final step of the nursing process, crucial to determine if the patient's condition improved or worsened after applying the first four steps of the nursing process
The nursing process is dynamic, cyclic, patient-centered, goal-directed, flexible, problem-oriented, cognitive, action-oriented, interpersonal, holistic, and systematic
Purpose of the nursing process:
To identify a client’s health status and health problems or needs
To provide individualized, holistic, effective, and efficient nursing care
To provide nursing interventions to meet those needs
To establish a plan of care to meet identified needs
Health assessment in nursing practice involves a deliberate and systematic collection of data to determine a client’s current and past health status, functional status, and coping patterns
4 Basic Types of Assessment:
Initial comprehensive assessment
Ongoing or partial assessment
Focused or problem-oriented assessment
Emergency assessment
Types of Health Assessment:
Initial Comprehensive Assessment: collection of subjective and objective data about the client's health, history, and lifestyle
Ongoing or Partial Assessment: data collection after the comprehensive database is established, focusing on body systems and holistic health patterns
Focused or Problem-Oriented Assessment: thorough assessment of a specific client problem
Emergency Assessment: rapid assessment in life-threatening situations
Nurse's role in health assessment varies based on the setting, such as acute care, critical care, ambulatory care, home health, public health, and more
Evolution of the Nurse’s Role in Health Assessment:
Late 1800s-Early 1900s: nurse's natural senses, all observable change, use of palpation, inspection, and auscultation
1930-1949: routine client and home inspection, prevention of communicable diseases
1950-1969: pre-employment health stories, active role in primary health services
1970-1989: expanded nurse role in health histories, physical, and psychological assessments
1900-Present: healthcare movement, critical pathways, advanced practice nurses