NURS 340 Exam 1 – Accurate Solutions For Every
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Terms in this set (164)
Subjective data information gathered from interview/history taking
-what the patient tells you or what the patient
STATES
-you can't prove or observe the data
-EX. pain
objective data information from your physical exam
-what is OBSERVED by inspecting, percussing,
palpating, auscultating
EX. BP, heart rate, vital signs
5 steps of nursing process (ADPIE) -assessment
-diagnosis
-planning
-intervention
-evaluation
,elements that are included in the -process used to evaluate the health status of a
assessment phase of the nursing person
process -systemic data collection that provides information
to facilitate a plan to deliver the best care
purpose of the health assessment -determine a patients health status
-determine patients risk factors
-determine the need for health education
-develop a nursing plan of care
complete health database describes current and past health state and forms
baseline to measure all future changes
what is included in a complete health -a complete health history
database -full physical examination
-yielding the first diagnosis
a comprehensive health assessment -patients current health problems
includes -past history
-family history
-review of body systems
-health patterns
when to obtain a complete health -every person needs a complete health assessment
history -ideally done on admission
-appropriate for new patients in all settings (nursing
home, home health care, new patients to a clinic)
3 types of databases focused, follow-up, emergency
focused (episodic/problem- -used for limited or short term problem
centered) database -appropriate for established patients
-smaller in scope and more targeted that complete
EX. labor and delivery
, follow-up database -evaluates the status of any identified problem at
regular intervals to follow-up on short-term and
chronic health problems
-evaluation of a previously identified problems
EX. patient had a hip replacement and came back to
hospital 14 days later for check up
emergency database -call for rapid collection of crucial data
-rapid assessment often occurs while performing
lifesaving measures
-assessing physically and TREATING
sign an objective, observable phenomenon that can be
identified by another person
symptom a subjective experience that cannot be identified by
anyone else
Evidence based practice is a systematic approach to practice that uses
research evidence, clinical expertise, clinician
knowledge, and the patients preferences and values
to make decisions about care and treatment
-multifaceted and reflects holistic care
Health relative state in which a person strives to meet their
potential and includes the area of wellness with the
ultimate goal of improving health
-not solely defined as the absence of disease but
rather by the contributions of all dimensions
Question
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Terms in this set (164)
Subjective data information gathered from interview/history taking
-what the patient tells you or what the patient
STATES
-you can't prove or observe the data
-EX. pain
objective data information from your physical exam
-what is OBSERVED by inspecting, percussing,
palpating, auscultating
EX. BP, heart rate, vital signs
5 steps of nursing process (ADPIE) -assessment
-diagnosis
-planning
-intervention
-evaluation
,elements that are included in the -process used to evaluate the health status of a
assessment phase of the nursing person
process -systemic data collection that provides information
to facilitate a plan to deliver the best care
purpose of the health assessment -determine a patients health status
-determine patients risk factors
-determine the need for health education
-develop a nursing plan of care
complete health database describes current and past health state and forms
baseline to measure all future changes
what is included in a complete health -a complete health history
database -full physical examination
-yielding the first diagnosis
a comprehensive health assessment -patients current health problems
includes -past history
-family history
-review of body systems
-health patterns
when to obtain a complete health -every person needs a complete health assessment
history -ideally done on admission
-appropriate for new patients in all settings (nursing
home, home health care, new patients to a clinic)
3 types of databases focused, follow-up, emergency
focused (episodic/problem- -used for limited or short term problem
centered) database -appropriate for established patients
-smaller in scope and more targeted that complete
EX. labor and delivery
, follow-up database -evaluates the status of any identified problem at
regular intervals to follow-up on short-term and
chronic health problems
-evaluation of a previously identified problems
EX. patient had a hip replacement and came back to
hospital 14 days later for check up
emergency database -call for rapid collection of crucial data
-rapid assessment often occurs while performing
lifesaving measures
-assessing physically and TREATING
sign an objective, observable phenomenon that can be
identified by another person
symptom a subjective experience that cannot be identified by
anyone else
Evidence based practice is a systematic approach to practice that uses
research evidence, clinical expertise, clinician
knowledge, and the patients preferences and values
to make decisions about care and treatment
-multifaceted and reflects holistic care
Health relative state in which a person strives to meet their
potential and includes the area of wellness with the
ultimate goal of improving health
-not solely defined as the absence of disease but
rather by the contributions of all dimensions
