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17 Cards in this Set

  • Front
  • Back

Assessment

Collecting subjective and objective data.

Diagnoses

Analyzing subjective and Objective data

Planning

Determining outcome criteria and developing a plan

Implementation

Carrying out the plan

Evaluation

Assessing whether the desire outcome has been met.

Purpose of Health Assessment

collect holistic subjective and objective data to determine a client's overall level of functionings.

ADL

Activities of Daily Living

Focus of Health Assessment

how the client's health status affects activities of daily living and how those activities of daily living affects the client's health.

Medical Assessment

focused only on clients physiologic status

Assessment

is the first and most critical phase of the nursing process

Initial Comprehensive Assessment

involves collection of subjective data about the client's perception of his or health (family history, patient health history)

Ongoing or partial assessment

consist of data collection that occurs after the comprehensive dats is established.

Focused or problem-oriented assessment

It consist of a thorough assessment of a particular client problem and does not address not related to the problem.

Emergency Assessment

A very rapid assessment that is performed in life threatening situations

Validating Objective data

to ensure that the assessment process is not ended before all relevant data have been collected, and helps to prevent documentation of inaccurate data

Documenting data

it forms the database for the entire nursing process and provides data for all other members of the health care team.

Nursing Diagnoses

provides the basis for selecting nursing intervention to achieve outcomes for which the nurse is accountable.