Term
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Definition
Includes core needs
Anxiety
sexuality
safety
mobility
sensation/perception
nutrition/metabolism
fluid & electrolytes
circulation
aeration
elimination |
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Term
| Comprehensive Assessment Data Collection (Systematic) |
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Definition
1. Body Sytems assessment tools
2. Problem Oriented |
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Term
| Assessment Data Collection |
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Definition
Client
Family members
Health care team
Medical record information
Scientific literature |
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Term
| Assessment Data Clustering |
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Definition
Look for deviations from normal patterns.
Core Needs
Gordon's Functional Health Patterns |
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Term
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Definition
What your client or significant other tells you
What you see,hear,feel,smell,measure |
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Term
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Definition
| Your judgement interpretation. |
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Term
| "short of breath for 2 days" |
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Definition
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Term
| "I've gained 10 pounds since last month" |
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Definition
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Term
| Weight 9/24/xx 200 pounds |
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
| 5 mm pitting lower extremities |
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Definition
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Term
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Definition
Symptom
Client's verbal description of the health problem.
Feelings,preceptions,self report of symptoms.
"I feel short of breath"(cue)
"I ate ham a a whole bag of salted peanuts" |
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Term
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Definition
Sign
Observations or measurements of a client's health status
Weight 190 pounds on 9/12/xx (cues only)
Weight 200 pounds on 9/19/xx |
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Term
| Analysis of Data- Problem and Stressors |
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Definition
| Note any discrepancies or distortions between client's or significant other's perception and the nurse. |
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Term
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Definition
Physiological
Psychological
Developmental
Spritual
Sociocultural |
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Term
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Definition
| Relationships of family,friends,caregivers |
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Term
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Definition
| Resources,finances,employment |
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