Term
| May be defined as a systematic method of collecting data about a client for the purpose of determining the clients current and ongoing health status, predicting risks to health, and identifying health-promoting activities. |
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Definition
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Term
| What does the health assessment include? |
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Definition
| interview, physical assessment, documentation, and interpretation of findings. |
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Term
| This is where subjective data are gathered, includes the health history and focused interview. |
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Definition
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Term
| information that the client experiences and communicates to the nurse. |
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Definition
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| What are some examples of subjective data? |
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Definition
| perceptions of pain, nausea, dizziness, itching sensations, or feeling nervous |
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Term
| What is the purpose of the health history? |
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Definition
| to obtain information about the clients health in his or her own words and based on the clients own perceptions. |
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| What are some types of information included in the health history? |
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Definition
biographic data
perceptions about health
past & present history of illness& injury
family history
a review of systems
health patterns and practices |
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Term
| what is the most important part of the assessment process? |
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Definition
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Term
| this enables the nurse to clarify points, to obtain missing information, and to follow-up on verbal and nonverbal cues identified in the health history |
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Definition
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Term
| is hands-on examination of the client |
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Definition
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Term
| what are the components of the physical assessment? |
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Definition
| survey and examination of systems |
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Term
| ______gathered during the physical assessment, when combined with all other reliable soures of information, provide a sound database from which care planning may proceed. |
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Definition
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Term
| this is observed or measured by the professional nurse. they are also known as overt data or signs since they are detected by the nurse |
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Definition
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Term
| This data can be seen, felt, heard or measured by the professional nurse |
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Definition
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Term
| What are some examples of objective data? |
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Definition
| skin color can be seen, a pulse can be felt, a cough can be heard, and a blood pressure can be measured |
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Term
| What is needed to validate the subjective data and to complete the database? |
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Definition
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Term
| Both subjective and objective data may further be categorized as what? |
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Definition
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Term
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Definition
| information that does not change over time such as race, sex or blood type |
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Definition
| information that may change within mintures, hours, or days. Ex: blood pressure, pulse rate, blood counts, and ages. |
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Term
| documentation of data from the health assessment creates _____ |
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Definition
| client record or becomes an addition to an existing health record. |
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Term
| legal document used to plan care, to communicate information between and among healthcare providers, and to monitor quality of care. |
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Definition
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Term
| Also, provides information used for reimbursement of services, is often a soure of data for research, and is reviewed by accrediting agencies to determine adherence to standards |
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Definition
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Term
| In order for the communication to be effective, the nurse must adhere to what guidelines for documention? |
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Definition
| documentation must be accurate, confidential, appropriate, complete, and detailed. |
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Term
| When recording ______, it is important to use quotation marks and to quote a client exactly rather than interpret the statement |
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Definition
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Term
| accepted terminology for documenation of findings includes the use of _____ |
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Definition
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Term
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Definition
Blue- (frontal plane) seperating anterior and posterior
Purple-(median plane)-seperating the body into right and left halves
Yellow-(horizontal plane) dividing the superior and inferior parts of the body.
(saggital plane) referring to any plane parallel to the median.
S |
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Definition
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Term
| protection of an individuals health information is regulated federally through what? |
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Definition
| Health Insurance Portability and Accountability (HIPAA) |
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Term
| Title II if HIPAA also known as ______, stipulates the requirements for maintaining the security and privacy of medical information |
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Definition
| Adminstrative Simplification |
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Term
| utilizes words, phrases, sentences, and paragraphs to record information. The information may be recorded in chronologic order from initial contact through conclusion of the assessment. |
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Definition
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Term
| includes words, sentences, phrases, or lists to indicate judgements made about the data, plans to address concerns, and actions taken to meet the health needs of the client. |
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Definition
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Term
| includes the SOAP and APIE methods |
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Definition
| Problem-oriented charting |
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Term
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Definition
Subjective data
Objective data
Assessment-conclusions drawn from the data
Planning |
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Term
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Definition
Assessment
Problem
Intervention
Evaluation |
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Term
| is a method that does not limit documentation to problems but can include client strengths. This type of documentation is intended to address a specific purpose or focus, that is, a symptom, strength, or need. |
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Definition
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Term
| What is the format for focus documentation? |
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Definition
| column to address subjective and objective data, nursing action, and client response |
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Term
| is a system in which documentation is limited to exceptions from pre-established norms or significant findings. |
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Definition
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Term
| this type of documentation eliminates much of teh repetition involved in narractive and other forms of documentation |
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Definition
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Term
| What is the advantage of using computer documentation? |
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Definition
| it allows healthcare providers to use more time recording appropriate information and less time determining the correct terms, spelling, and descriptors. |
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Term
| defined as making determinations about all of the data collected in the health assessment process |
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Definition
| interpretation of findings |
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Term
| interpretation of findings is influenced by a number of factors. what are they? |
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Definition
| ability to obtain,recall, and apply knowledge; to communicate effectively; and to use a holistic approach |
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Term
| can be defined as considering more than the physiologic health status of a client. It includes all factors that impact the client's physical and emotional well-being. |
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Definition
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Term
| In this approach, the nurse recognizes the developmental, psychologic, emotional, family, cultural, and environmental factors will affect immediate and long-term actual and potential health goals, problems, and plans. |
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Definition
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Term
| systematic, rational, dynamic, and cyclic process used by teh nurse for planning and providing care for the client. |
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Definition
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Term
| What is the five-step nursing process? |
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Definition
1. assessment-collection, organization, and validation of subjective and objective data.
2. diagnosis-uses critical thinking and applies knowledge from the sciences and other disciplines to analyze and synthesize the data. basis for planning and implementing nursing care
3. planning-involves setting priorities, stating client goals or outcomes; and selecting nursing interventions, strategies, or orders to deal with the health status of the client.
4. implementation-putting the nursing interventions into action
5. evaluation |
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Term
| What are the 3 types of nursing diagnoses that are identified within the NANDA taxonomy? and give an example for each. |
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Definition
actual problems-ineffective breathing pattern is a diagnostic statement which exemplifies an actual problem
risks for problems-at risk for suicide
wellness issues-readiness for enhanced family coping |
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Term
| Each NANDA diagnosis is composed of what 4 components? |
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Definition
diagnostic label
a definition
defining characteristics
risks or related factors |
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Term
| NANDA diagnoses are formulated using a ____ statement |
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Definition
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Term
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Definition
The problem (P) is the diagnostic label
The etiology(E) includes the cause and contributing factors
The signs & symptoms(S) are the defining characteristics |
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| What is Mrs. Jacobs PES statement? |
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Definition
(P) constipation
(E) related to lack of knowledge
(S) as evidenced by abdominal distention, achy abdomen, infrequent hard stool, and low fluid intake |
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