NURS303 Lecture Notes - Lecture 13: Nursing Assessment, Nursing Process, Data Validation
15 Dec 2017
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Document Summary
Nursing process = problem solving approach to identifying, diagnosing and treating health issues. Assessment gathering and analysis of information about client"s health status. Diagnosis make clinical judgments about client"s response to health problems in nursing diagnoses. Planning individualized interventions to each of nursing diagnoses. Evaluation of client"s response and determine if interventions effective. Collection and verification of data from primary and secondary sources. Analysis of al data as basis for developing diagnoses, identifying problems and developing an individualized plan. Main purpose = establish a database about the client"s perceived needs, health problems etc. Experience previous client experience, validation of assessment findings, observation of assessment techniques. Learn to differentiate important data from total data. Cue information collected through use of senses. Inferences judgment or interpretation of the cues. Begin with comprehensive nursing health history (box 12-1) guideline for documentation. Identifying data name, age, sex, date of birth. Source of history relationship to client, use of interpreter.
