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11 Cards in this Set

  • Front
  • Back
What is the purpose of assessment?
To gather subjective and objective data about the patient.
What is the difference between objective data and subjective data?
Data obtained from the patient verbally are subjective data
How is a database compiled?
Interview, Physical assessment, talking with the family and significant others, and communication with other health professionals, and chart review
What is done to gather information for the nursing database?
Chart Review
What is performed at admission?
Nursing history and assessment
What should the nurse do at the beginning of each shift?
A quick head-to-toe assessment
What does a nursing diagnosis statment indicate?
The patient's actual health status, or a potential problem, the causative factors and specific S&S
What is the accepted list that nursing diagnoses should be taken from?
The nursing care plan should be documented when?
Soon after admission assessment, the nursing care plan should be documented.
How often is the nursing care plan reviewed and updated?
Every 24 hours
What is the role of the LPN in the patient assessment?
Assists with the admission assessment