Looking, Listening, Feeling, Smelling ---Do the above in order too ---Assess, Diagnosis, Plan, Implement, and Evaluate

. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation Each step is dependent on the accuracy of the step preceding it.

AssessmentData Collection is a Primary Tool

Puzzle Pieces Gathering Info about pt Data collection requires us to examine the data Does it fit the picture? Formal vs Informal Pt is our primary source for this data What are secondary sources?

Focus vs Data Base Assessment

Focus Asst is performed to gather detailed information about a specific condition. Baseline Data - is gathered on initial contact with pt to gather info about all aspects of health status

Two types of data

S Subjective - What the patient tells you Subjective = Statements Im itching O Objective Detectable by an observer or can be tested O = Objective What are some examples

Nursing Diagnosis Process

Data Validation \ > Interpretation of Data Clustering / Data \/ Identification of Client needs \/ Formulation of Nursing Diagnosis

Organizing data
Your assessment tool will assist you with this Clustering into categories helps you get a better picture Maslows Heiarchary of Needs helps you too

Steps in data analysis

1. Do you see a pattern or trend 2. Compare your data to Standards (Norms) i.e., B/P 168/102 (Normal 110/70) Rales heard in lung fields ( Normal clear lung sounds) 3. Make a reasonable conclusion

Four Methods Nurses use to: Collect Data

. Interview 2. Nursing Health History 3. Physical Examination Head 4. Diagnostic and Laboratory Results