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16 Cards in this Set

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Assessment
Systematic collection of data relating to patiends and their problems.
Auscultation
Listening to sounds produced by the body, such as heart,lung, and intestinal sounds .
Critical thinking
Reflective and reasonable thinking that focused on deciding what to belience or do
Evaluation
Assessing the achievement of goals and changing the plan as indicated by current needs.
Evidence-based practice
Evolved as a mechanism to convert research findings to useful practice guidelines.
Focused Assessment
One or Two systems evaluated depending on patients symptoms.
Implementation
Putting plan in to action
Inspection
Purposeful observation of the person as a whole and then systematically from head to toe.
Nursing Diagnosis
Interpretation of the data for problem identification.
Nursing Process
Systematic method of providing care to patients.
Objective Data
Using five senses to obtain data with physical examination,diagnostic tests , and patient records.
Palpation
Using the senses of touch to assess various parts of the body and helps confirm findings that are noted on inspection.
Percussion
is tapping on the skin to assess the underlying tissue
Planning
Goals and Selected interventions
Problem-oriented medical record(POMR)
Documentation format
Subjective Data
Consists of information that is reported by patient and family.