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11 Cards in this Set
- Front
- Back
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data analysis
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analyzing each piece of information to determine its relationship to a client's health problems and its relationship to other pieces of information
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health interview
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way of soliciting information from the client; may also be called a nurisng history
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nursing assessment
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systematic and continous collection and analysis of information about the client
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nursing history
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way of soliciting information from the client, may also be called a health interview
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nursing progress notes (nursing notes)
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documentation by nurses of care given and observations made; charting data input
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objective data
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all measurable and observable pieces of information about a client and his or her overall state of health
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observation
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assessment tool that relies on the use of the five senses to discover objective information about the client.
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potential needs
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in the nursing process needs which may occur, identified as "at risk for"
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subjective data
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information that consists of the clien'ts opinions and feeling abot what is happening, conveyed to the nurse either directly or through body language
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ADL
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activities of daily living
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CC
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chief compliant
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