Nursing Fundamentals Chapter 11

Front 1

Assessing

Back 1

systematic and continuous collection, analysis, validation, and communication of patient data, or information

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database

Back 2

includes all the pertinent patient information collected by the nurse and other health care professionals

Front 3

nursing history

Back 3

identifies the patients health status, strengths, health problems, health risks, and need for nursing care

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purposeful

Back 4

identify the purpose of the nursing assessment

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prioritized

Back 5

get the most important information first

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complete

Back 6

as much as possible, identify all the patient data needed to understand a patient health problem and develop a plan of care the maximize the patients well being

Front 7

systematic

Back 7

use a systematic way to gather data

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factual and accurate

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nurses concerned with accuracy and factual reality continually verify what they hear with what they observe, using other senses and validating all questionable data.

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relevant

Back 9

determine what types of and how much data to collect for each patient. aim is to record concisely all pertinent data

Front 10

recorded in a standard manner

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information needs to be recorded according to agency policy so that all caregivers can easily access what you learned

Front 11

assessments include

Back 11

comprehensive initial assessment, focused assessment, emergency assessment, and the time-lapsed assessment

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initial assessment

Back 12

performed shortly after the patient is admitted to a health care agency or service, used to establish a complete database for blame identification and care planning, baseline for future comparison

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focused assessment

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nurse gathers data about a specific problem that has already been identified, ongoing data collection, identify new or overlooked problems

Front 14

QPA

Back 14

Quick priority assessments, short, focused, prioritized assessments you do to gain the most important information you need to have first, important because they can "flag" existing problems and risks

Front 15

emergency assessment

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identify life threatening problems

Front 16

time-lapsed assessments

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scheduled to compare a patients current status to the baseline data obtained earlier, used to reassess their health status and make necessary revision in the plan of care

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minimum data set

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specifies the information that must be collected from every patient and uses a structured assessment form to organize or cluster this data

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subjective data

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information perceived only by the affected person, nervous, nauseated, chilly, pain, also called symptoms or covert data

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objective data

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observable and measurable data that can be seen, heard, felt or measured by someone other than the person experiencing them. also called signs or overt data

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consultations

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patients physicians may invite specialists to assess and treat the patient, focus is to find additional findings related to the patients medical diagnosis and treatment

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observation

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key nursing skill when performing both the nursing history and the physical exam, the conscious and deliberate use of the five senses to gather data

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interview

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is a planned communication used to obtain the nursing history

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phases of interview

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preparatory phase, introduction, working phase, and termination

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physical assessment

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examination of the patient for objective dad that may better define the patients condition and may help the nurse plan care. nursing physical assessment focuses primarily on the functional abilities of the patient

Front 25

Review of systems (ROS)

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the examination of all body systems in a systematic matter, commonly using a head to toe format. Four methods are used: inspection, palpation, percussion and auscutation

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inference

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the judgement you reach about the cue, inferences need to be validated

Front 27

validation

Back 27

the act of confirming or verifying, purpose is to keep data as free from error, bias, and misinterpretation as possible