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16 Cards in this Set

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Assessment
Nursing assessment includes two steps. The first step involves the collection and verification of data from a primary source (the client) and secondary sources (e.g., family, health professionals, and medical record). The second step involves the analysis of all data as a basis for developing nursing diagnoses and an individualized plan of care for the client.
Data
The second step of assessment involves the analysis of all data as a basis for developing nursing diagnoses and an individualized plan of care for the client.
Database
The purpose of the assessment is to establish a database about the client's perceived needs, health problems, and responses to these problems. In addition, the dataq reveal related experiences, health practices, goals, values, and expectations held about the health care system.
Positive Data
Information that indicates a deviation from normal and suggests illness
Negative Data
Information which indicates there is no deviation from normal
Limitations
Limitations of client
Strengths
Strengths of client
Observation
Gather data by using 4 senses
sight, touch, smell, hearing
Examination
Also involves senses but is more sophisticated and frequently involves using an instrument
Inspection, Auscultation, Palpation, Percussion
Focus Assessment
In-depth assessment of a primary problem
Primary sources of data
Given by the client
usually most accurate - depends on mental status
Secondary sources of data
From significant other, health team, medical record
Subjective Data
subjective (symptom) - what is told, cannot be measured, observed, or validated
Objective Data
objective (sign) - observable, measurable
Cues
Information that the nurse acquires through the use of the five senses.
Inferences
judgements we make based on cues