subjective data - Answers What the person says about themselves
objective data - Answers what the health professional observe by inspecting, percussing,
palpating, and auscultating
Database - Answers patient's record and laboratory studies
Purpose of assessment - Answers to make judgement or diagnosis
Assessment - Answers collection of data about individual's health state
biomedical model - Answers western tradition that views health as absence of disease
critical thinking - Answers simultaneously problem-solving while self-improving one's own
thinking ability
diagnostic reasoning - Answers method of collecting and analyzing clinical info w/ attending to
initial cues, formulating diagnostic hypotheses, gathering data to support hypothesis, evaluating
each hypothesis w/ new data collected, arriving at final diagnosis
emergency database - Answers rapid collection of database, often compiled concurrently w/
lifesaving machines
environment - Answers the total of all conditions & elements that make up surroundings &
influence development of person
evidence-based practice - Answers a systemic approach emphasizing the best research
evidence, the clinician's experience, patient preferences and values, physical examination, &
assessment
focused database - Answers used for a limited/short-term problem; concerns mainly one
problem, one cue complex, or one body system
follow-up database - Answers used in all setting to monitor progress on short-term or chronic
health probs
holistic health - Answers view that mind, body, and spirit are interdependent & function as whole
with environment
medical diagnosis - Answers to evaluate the cause and etiology of disease; focus = function or
malfunction of a specific organ system
nursing diagnosis - Answers used to evaluate response of whole person to actual or potential
health problems
nursing process - Answers method of collecting & analyzing clinical info w/ the following
, components: assessment, diagnosis, outcome identification, planning, implementation,
evaluation ADOPIE
prevention - Answers any action directed toward promoting health & preventing occurrence of
disease
wellness - Answers a dynamic process & view of health; a move toward optimal funcitoning
first level priority problems - Answers emergent, life-threatening, immediate
(Airway problems
Breathing
Cardiac/Circulation
Vital sign concerns
Second level priority problems - Answers next in urgency problems (mental status change,
acute pain, urinary elimination problem..)
3rd level priority problems - Answers important to patient's health but can be addressed after
more urgent health probs
collaborative problems - Answers approach to treatment involves multiple disciplines
inspection - Answers watching; observing close
palpation - Answers touching to assess texture, temperature, moisture, organ location, & size,
swelling, vibration, pulsation
percussion - Answers tapping person's skin with short sharp strokes to assess underlying
structures
ascultation - Answers listening to sounds produced by body with stethoscope
diaphragm - Answers for high-pitched sounds, breath, bowel and normal heart sounds
bell - Answers soft, low-pitched sounds (extra heart sounds, murmurs)
otoscope - Answers funnels light into ear canal and onto tympanic membrane
ophthalmoscope - Answers illuminates internal eye structure
nosocomial infection - Answers an infection acquired during hospitalization
amplitude - Answers intensity; how loud or soft a sound is
duration - Answers the length of time a note lingers