1. Sources of assessment
what the RN observes, data from the chart, report from others on the health care team and
subjective vs. objective data
2. What is clustering
organizing items into related groups
3. Recogn
...
1. Sources of assessment
what the RN observes, data from the chart, report from others on the health care team and
subjective vs. objective data
2. What is clustering
organizing items into related groups
3. Recognize Gordon’s Functional Health Pattern classifications (11 general ones)
health perception/health management
activity and exercise
metabolism
elimination
sleep-rest
cognitive – perceptual
self-perception - self-concept
role - relationship
sexuality – reproductive
coping - stress tolerance
values - beliefs
4. Differentiate between subjective and objective data
subjective is what the patient says, objective is what I can observe
5. Identify the primary source for assessment datapatient
6. Recall that REASSESSMENT is needed throughout the nursing process
before modifying a care plan, reassess the patient’s response to the
initial interventions
T. RESSASEMENT AND EVALUATION TOGETHER
7. What are the Joint Commission Guidelines related to assessment? HINT: Who is
allowed to complete the assessment?
the nurse, RNs can't delegate patient assessments to CNAs.
T. ACTION RULE IS YOU HAVE TO GO AND RESSASE THE PAIN ASSESSMENT
FOR THE PATIENT. IT IS NURSE JOB TO COMLETE THE ASSESSMENT
8. Examples of types of data that need to be validated…Hint = incongruent information
incongruent objective data or discrepancies, any changes in status
Nursing Diagnosis
1. Explain what the nurse does to formulate a nursing diagnosis (What is needed?
problem, r/t etiology, AEB symptomatic support - defining characteristics
2. Be able to give reasons why we use nursing diagnoses
to prioritize and individualize care
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