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TYPES OF ASSESSMENT:
TYPE TIME PURPOSE EXAMPLE
PERFORMED
Initial Within specified To establish a Nursing
Assessment time after complete data admission
admission base for problem assessment
identification,
reference and
future
comparison
Problem-focused Ongoing To determine I & O q 1 hr in
assessment process status of specific ICU
integrated with problem
nursing care identified in an
earlier
assessment Assess client’s
To identify new ability to perform
or overlooked self care while
problems assisting to
bathe
Emergency During any To identify life- Rapid
Assessment physiologic threatening assessment of
and problems ABC during
psychologic cardiac arrest
crisis of the Assessment for
client suicidal
tendencies and
potential for
violence
Time-lapsed Several months To compare Reassessment of
reassessment after initial client’s current client’s
assessment status to functional health
baseline data patterns.
previously
obtained
A. DATA COLLECTION – is the process of gathering info about a client’s
health status.
DATABASE – is all info about the client; includes nursing health history,
physical assessment, doctor’s history and physical exam, results of lab and
diagnostic tests, and material contributed by other health personel.
TYPES OF DATA:
SOURCES OF DATA:
1. PRIMARY DATA – from the CLIENT, it is the best source of data unless
too ill, young, confused to communicate clearly.
QUALIFIERS – are words that have been added to some NANDA labels to give
additional meaning to the diagnostic statement.
• Decreased – lesser
b. cluster cues
b. Using the phrase complex factors when there are too many
etiologic factors or when they are too complex to state in a brief
phrase.
• Prioritize problems/diagnosis
TYPES OF PLANNING
NURSING CARE PLAN. Is the end product of the planning phase of the
nursing process
STANDARDIZED CARE PLANS. They are preprinted guides for the nursing
care of a client who has a need that arises frequently in the agency. They
written from the perspective of what care the client can expect.
COMPONENTS
a. Subject. Is the client, any part of the client, or some attributes such
as BP/ Temp.
IMPLEMENTING SKILLS
• INTERPERSONAL SKILLS -