Patient assessment: Obtains and documents nursing history from the patient and/or significant other that is comprehensive of present condition and prior problems. Performs basic assessment of the patient, indicating adequate knowledge of anatomy, physiology, and pathology. Records vital signs, notes changes, and pursues more-specific investigation as needed. Makes pertinent observation, using language that correctly describes body parts and functions, and draws logical conclusions which direct formation of nursing care plan. Identifies abnormal diagnostic data and shows a fundamental understanding of its implications by reporting information to the physician and others caring for the patient, and by incorporating information in the nursing care plan.
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