A health history provides a holistic view of a patient's health care experiences and current health habits Show Assess whether a patient has ever been hospitalized or injured or has had surgery. Include a complete medication history Review the use of any prescription medications, herbal supplements, and over-the-counter drugs. Assessing for the use of alcohol, tobacco, caffeine, or recreational drugs determines a patient's risk for diseases involving the liver, lungs, heart, or nervous system. Recommended textbook solutions
 Pharmacology and the Nursing Process7th EditionJulie S Snyder, Linda Lilley, Shelly Collins 388 solutions
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Law and Ethics for Health Professions9th EditionCarlene Harrison, Karen Judson 836 solutions an identification by a nurse of the needs, preferences, and abilities of a patient. Assessment includes an interview with and observation of a patient by the nurse and considers the symptoms and signs of the condition, the patient's verbal and nonverbal communication, the patient's medical and social history, and any other information available. Among the physical aspects assessed are vital signs, skin color and condition, motor and sensory nerve function, nutrition, rest, sleep, activity, elimination, and consciousness. Assessment is extremely important because it provides the scientific basis for a complete nursing care plan. a statement of a health problem or of a potential problem in the client's health status that a nurse is licensed and competent to treat. Four steps are required in the formulation of a nursing diagnosis. A data base is established by collecting information from all available sources, including interviews with the client and the client's family, a review of any existing records of the client's health, observation of the client's response to any alterations in health status, a physical assessment, and a conference or consultation with others concerned in the client's care. The data base is continually updated. The second step includes analysis of the client's responses to the problems, healthy or unhealthy, and classification of those responses as psychologic, physiologic, spiritual, or sociologic. The third step is the organization of the data so that a tentative diagnostic statement can be made that summarizes the pattern of problems discovered. The last step is confirmation of the sufficiency and accuracy of the data base by evaluation of the appropriateness of the diagnosis to nursing intervention and by the assurance that, given the same information, most other qualified practitioners would arrive at the same nursing diagnosis. In use, each diagnostic category has three parts: the term that concisely describes the problem, the probable cause of the problem, and the defining characteristics of the problem. Students also viewedRecommended textbook solutions
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What is assessment in nursing quizlet?collection of data through observation, interview, examination, intuition, patients, family, records, etc.
What is the primary purpose of the nursing diagnosis quizlet?4. What is the primary purpose of the nursing diagnosis? Each nursing diagnosis label identifies either a patient problem or need, which is its purpose.
How is assessment defined as part of the nursing process quizlet?Define nursing assessment, including the four features common to all its definitions. Assessment is a systematic, ongoing process of collecting, categorizing, and recording holistic data about client health status. Explain how assessment is related to each of the other steps of the nursing process.
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