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| Is they systematic and continuous collection, validation, analysis, and communication of patient data. |
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| Includes all the pertinent patient information collected by the nurse and other healthcare professionals. |
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| Identifies the patient's health status, strengths, health problems, health risks, and need for nursing care. |
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| Is performed shortly after the patient is admitted to a healthcare agency or service. |
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The nurse gathers data about a specific problem that has already been identified: Helpful questions include:
- What are your symptoms?
- When did they start?
- Were you doing anything different than usual when they started?
- What makes your symptoms better? Worse?
- Are you taking any remedies (medical or Natural) for your symptoms?
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Definition
| To identify life-threatening problems. |
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| Is scheduled to compare a patient's current status to baseline data obtained earlier. |
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| Are information percieved only by the affected person. (patient will tell you this information) ex: My are hurts or I have a headache. Their symptoms. |
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| Are observable and measurable data that can be heard, seen, or felt by someone other than that person experiencing them. Use your senses. |
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Definition
| Specifies the information that must be collected from every patient and use a structured assessment form to organize or cluster this data. |
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Definition
| Is the conscious and deliberate use of the five senses to gather data. |
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Definition
| Is a planned communication, where you will get a history on your patient. |
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| Is the examination of the patient for objective data that may better define the patient's condition and help the nurse in planning care. |
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Definition
The nursing physical assessment involves the examination of all the body sustems, ROS, in a systematic method manner, commonly using a head-to-toe format.
Four methods are used
- Inspection
- Palpation
- percussion
- ausculation
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Term
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Definition
| Is the act if confirming or verifying. The purpose of validating is to keep data as free from error, bias, and misinterpretation as possible. |
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A hint that something may be wrong.
For example: a patient doesnt respond when you speak to them. |
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Definition
The judgement you reach about the cue.
example: the patient may be deaf, which is why they are not responding to you. |
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