general survey

• Data Collection - gathering subjective and objective data
• Sources of data - primary source and secondary source
• Data Analysis - interpretting the collected data to identify patients problem
• Nursing diagnoses - differentiating nursing diagnose medical diagnoses and collaborative problems
• Setting goal and outcomes - developing measurable and achievable short term and long term goal
• Careplan - specific interventions to address the diagnosed problem
• Carrying out the plan - executing the planned intervention which may include adminestering medication, providing medication, or coordinating with other health professionals
• Documentation - Recording all interventions and patient responses
• Assessing outcomes - evaluating whether the goals where met and the effectiveness of interventions and patients responses
• Revising the plan - modifying the care plan as necessary based on the patients progress or lack thereof
• subjective data - patient's perceptions, feelings, and concerns
• objective data - measurable and observable information such as vital signs, physical examination findings
• Components -Detailed health history
• Purpose - Establishes a baseline for future comparisons and identifies any current health problems.
• Frequency - Conducted at regular intervals (daily, weekly, or at each shift).
• Focus - Monitoring the status of previously identified problems and detecting new problems.
• Scope - Targeted towards a specific health issue or body system.
• Process - Involves collecting data related to the current concern (e.g.. assessing respiratory function in a patient with shortness of breath).
• Nature - Rapid and immediate, addressing life-threatening situations.
• Components - Quick collection of essential data to stabilize the patient, such as assessing airway, breathing, circulation, and consciousness level.
• Communication Skills - Effective communication with patients, families, and other healthcare providers is essential for accurate data collection and ensuring patient-centered care.
• Cultural Competence - Understanding and respecting cultural differences in health beliefs and practices to provide culturally sensitive care.
• Documentation - Accurate and thorough documentation of assessment findings is crucial for continuity of care and legal purposes.
• Ethical Considerations - Ensuring patient privacy and confidentiality during the assessment process.
• Performing comprehensive assessments: Collecting detailed patient data to understand health status.
• Monitoring health: Regularly updating assessments to track changes in the patient's condition.
• 1. Identifying problems: Recognizing and diagnosing health issues based on assessment data.
• 1. Planning care: Developing individualized care plans with clear, achievable goals.
• 1. Implementing interventions: Providing necessary treatments and interventions based on the care plan.
• 1. Evaluating outcomes: Assessing the effectiveness of interventions and modifying the care plan as needed.
• 1. Educating patients: Teaching patients about their health conditions and promoting healthy lifestyle choices.
• Advocating for patients: Ensuring that patients' needs and preferences are respected in the care process.
• assessment - A in ADPIE
• Diagnosis - D in ADPIE
• Planning - P in ADPIE
• Implementation - I in ADPIE
• Evaluation - E in ADPIE
• Specific - S for SMART
• Measurable - M for SMART
• Attainable - A for SMART