Term
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Definition
Assessing
Diagnosing
Planning
Implementing
Evaluating |
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Term
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Definition
-collect data
-organize data
-validate data
-document data |
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Term
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Definition
-analyze data
-identify health problems, risks and strengths
-formulate diagnostic statements |
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Term
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Definition
-prioritize problems/diagnoses
-formulate goals/desired outcomes
-select nursing interventions
-write nursing interventions |
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Term
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Definition
-reassess the client
-determine the nurse's need for assistance
-implement the nursing interventions
-supervise delegated care
-document nursing activities |
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Term
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Definition
-collect data related to outcomes
-compare data with outcomes
-relate nursing actions to client goals/outcomes
-draw conclusions about problem status
-continue, modify, or terminate the client's care plan |
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Term
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Definition
symptoms or covert data
-apparent only to the person affected and can be described or verified only by that person
-subjective data include the client's sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situation |
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Term
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Definition
signs or overt data
-detectable by an observer or can be measured or tested against an accepted standard. |
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Term
sources of data:
primary
secondary |
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Definition
primary: client is primary source
secondary: family members, other support persons, health professionals, records and reports, lab and diagnostic analyses, and relevant literature |
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Term
| Components of Health History |
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Definition
Biographic Data-name, address, age, sex, marital status, occupation, religious preference, health care financin
Chief Complaint or reason for visit
History of present illness
Past history-illnesses, immunizations, allergies, injuries, hospitalizations, medications
Family history of illness
Lifestyle-personal habits, diet, sleep patterns, ADLs, recreation/hobbies
Social data-family relationships, ethnic affiliation, education history, occupational history, economic status, home/neighborhood conditions
Psychological data-major stressors, usual coping pattern, communication style
Patterns of health care-health care resources client is currently using and has used in past including primary care giver, specialist, dentist, health clinic, folk practioner |
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Term
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Definition
Observing- a)noticing the data b) selecting, organizing and interpreting data
Interviewing-directive-nurse establishes purpose of the interview and controls the interview
-nondirective-nurse allows client to control the purpose, subject matter and pacing
Examining-physical examination or physical assessment |
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Term
| Physical Assessment (Examination) |
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Definition
| systematic data collection method that uses observation (senses of (sight, hearing, smell, and touch) to detect health problems. To conduct the exam the nurse uses techniques of inspection, auscultation, palpation and percussion |
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Term
| Maslow's Hierarchy of Needs |
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Definition
Physiological needs (survival needs)
Safety and security needs
Love and belonging needs
Self-esteem needs
Self-actualization needs |
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Term
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Definition
| subjective or objective data that can be directly observed by the nurse: what the client says, or what the nurse can see, hear, feel, smell or measure. |
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Term
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Definition
| nurse's interpretations or conclusions made based on the cues |
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Term
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Definition
| is a systemic, rational method of planning and providing individualized nursing care for individuals, families, communities, and groups |
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