Chp. 1 Assessment: collection of relevant data to determine current health status, coping patterns, needs and problems.

3 activities: collecting data, grouping findings, and writing the nursing diagnosis. Data collection: interview, physical exam, observation, review records, and diagnostic reports; collaboration with other health care workers. Two levels of data collection (comprehensive data) Screening, or database, assessment Focused assessments Screening assessment Performed during initial contact with child. Gather info about childs health (baseline data) Childs developmental and immunization history Focused assessment: used to gather info specifically related to an actual health problem or a problem the child is at risk of getting Performed at beginning of shift; relevant to the childs diagnosis and current status Nursing diagnosis: data is analyzed to identify problems or potential problems. Data is validated and grouped Nursing diagnosis provides basis for nursing accountability for interventions & outcomes Nursing Diagnosis 3 categories: Actual nursing diagnosis: things on going with patient (patient is affected by these things) Risk for Nursing diagnosis: pts responses to health conditions or processes that may develop in an individual (supported by risk factors) Wellness nursing diagnosis: describe human response to wellness in an individual, family, or community (can get better and reach higher health level)