Mosby items and derived items © 2005 by Mosby, Inc. Chapter 16 Nursing Assessment Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Nursing Process Steps Assessment Nursing diagnosis Planning Implementation Evaluation Mosby items and derived items © 2005 by Mosby, Inc.

Nursing Process (cont'd) Assessment Critical thinking approach Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Assessment - Steps Collection and verification of data Analysis of data Mosby items and derived items © 2005 by Mosby, Inc.

Assessment - Approaches Use of a structured database format Problem oriented Mosby items and derived items © 2005 by Mosby, Inc.

Assessment – Data Collection Types of data Objective Subjective Sources of data Primary Secondary Mosby items and derived items © 2005 by Mosby, Inc.

Assessment – Methods of Data Collection Interview Orientation phase Working phase Termination phase Nursing health history Components Physical examination Diagnostic and laboratory results Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Assessment Process Nursing judgments Data validation and interpretation Data clustering Documentation Mosby items and derived items © 2005 by Mosby, Inc.