N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide

Assessment

Evaluation

Diagnosis/Analysis

Implementation & Intervention

Planning

1.1 Assessment The nursing process begins with the assessment of the patient. In the assessment phase, the nurse collects, organizes, validates, and documents information about the patient. This part of the nursing process is critical because the information obtained in this stage forms the foundation for the subsequent stages. Purpose of the Assessment The purpose of each assessment of the patient is to: • Collect and organize data about the patient’s physical and psychosocial health in order to identify potential and actual healthproblems • Assess the patient’s functional health and ability to care forhimself • Identify any dysfunctions in the patient’s activities of daily living (ADL) that may impair or impede optimal health • Provide the patient with an opportunity to discuss health concerns and goals withthe nurse Types of Assessments Assessment is not a one-time event. Some sort of assessment is done every time the nurse has contact with the patient or family. There are three types of assessments that the nurse completes: • The comprehensive assessment is the full baseline assessment by the nurse typically done at the time of the initial contact with the patient. This assessment includes a complete health history and current needs assessment that will allow the patient and healthcare team to create measureable goals for the patient. • A focused assessment is one that is limited, and focuses on a particular healthcareconcern or

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