Term
| What are the 2 steps for Nursing Assessment? |
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Definition
1 collection and verification of data from a primary sourse/client and a secondary sources/family or health professional
2 analysis of all data as a basis for developing nursing diagnoses, identifying collaborative problems, and developing a plan of individualized care |
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Term
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Definition
| purpose of assessment is to establish this; about client's perceived needs, health problems, and responses to these problems |
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Term
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Definition
| professional nurse's approach to identify, diagnose, and treat human responses to health and illness |
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Term
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Definition
| information that you obtain through use of the senses |
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Term
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Definition
| judgement or interpretation of those cues |
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Term
| Functional Health Patterns |
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Definition
| Gordon's 11 patterns from 1994 |
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Term
| Health perception-health management pattern |
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Definition
| describes the client's self-report of health and well-being ; how client manages health |
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Term
| Nutritional-metabolic pattern |
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Definition
| describes the client's daily/weekly pattern of food and fluid intake |
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Definition
| describes patterns of excretory function(bowel, bladder) |
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Term
| Activity-exercise pattern |
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Definition
| describes patterns of exercise, activity, leisure and recreation; ability to perform activities of daily living |
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Definition
| describes patterns of sleep, rest, and relaxation |
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Term
| Cognitive-perceptual pattern |
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Definition
| describes sensory-perceptual patterns; language adequacy, memory, decision making ability |
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Term
| Self-perception-self-concept pattern |
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Definition
| describes client's self-concept pattern and perceptions of self (body image, self concept/worth, emotional patterns) |
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Term
| Role-relationship pattern |
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Definition
| describes the client's patterns of role engagements and relationships |
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Term
| Sexuality-productive Pattern |
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Definition
| describes the client's patterns of satisfaction and dissatisfaction with sexually pattern; client's reproductive patterns; premenopausal and postemenopausal problems |
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Term
| Coping-stress tolerance pattern |
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Definition
| describes the client's ability to manage stress; sources of support; effectiveness of the patterns in terms of stress tolerance |
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Definition
| describes patterns of values, beliefs(including spiritual), and goals that guide the client's choices or decisions |
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Definition
| your client's verbal descriptions of their health problems |
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Term
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Definition
| observations or measurements of a client's health status |
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Definition
| an organized convo w/ the client |
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Term
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Definition
| includes data about the client's current level of wellness, including a review of body systems, family and health history, socioculteral history, spiritual history, and mental & emotional reactions to illness |
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Term
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Definition
| prompts a client to describe a situation in more than 1 or 2 words |
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Definition
| includes active listening such as "uh-huh" and "go on" |
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Term
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Definition
| systematic method for collectin data on all body systems; ask client about normal functioning of each body system and any noted changes |
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Term
| Validation of assessment data |
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Definition
| comparison of data with another source to determine data accuracy |
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Term
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Definition
| involves recognizing patterns or trends in the clustered data comparing them with standards, and then coming to a reasoned conclusion about the client's responses to a health problem |
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