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