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NR 302 (Health Assessment I) Exam I Study Guide; Updated A+ Guide

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1. Steps of Nursing Process – be able to identify and apply Nursing process definition: a systematic, organized method of practicing nursing What are the 6 steps of the nursing process? Assessment... Diagnosis Outcome Identification Planning Implementation Evaluation Assessment - collect as much data - physical findings, historical information, verbal and non-verbal observations, medical records, self-care abilities, psycho-social implications In which stage of the nursing process does the nurse review the clinical record and obtain a health history, amongst other tasks? ASSESSMENT Diagnosis - Nursing diagnosis, not medical diagnosis -the only acceptable diagnosis from the North American Nursing Diagnosis Association ( NANDA ) Identification of a disease or condition by scientific evaluation of physical signs and symptoms Outcome Identification 1) Identify expected outcomes 2) individualize to the person 3) culturally appropriate 4) realistic and measureable 5) include a timeline Planning 1) Establish priorities 2) develop outcomes 3) set timelines for outcomes 4) identify interventions 5) integrate evidence-based trends and research 6) document plan of care [Show More]

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