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Related Flashcards
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Cards In This Set
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The collection of data about an individual's health state
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Assessment
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Formed by the collection of data about and individual's health state as well as patient's record and laboratory studies
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Database
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What a person says says about himself or herself during history taking
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Subjective data
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What you as the health profession observe by inspecting, percussing, palpating, and auscultating during the physical examination
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Objective data
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The process of analyzing health data and drawing conclusions to identify diagnoses, is based on the scientific method
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Diagnostic reasoning
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List the 6 phases of the nursing process
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Assessment, diagnosis, outcome identification, planning, implementation, and evaluation
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Explain the nursing model
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Used along with, but in place of the medical. Is needed to focus assessment on core nursing concerns such as nutrition, activity, hygiene, skin, problems, coping problems, or self care limitations.
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Clinical judgments about a person's response to an actual or potential health state
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Nursing diagnosis
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What makes the nursing model different from the medical model
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Nurses use the medical model when working interdependently with the physician in the diagnosis and treatment of disease
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Topic A of health history; includes name, address, phone #, age, and birth date, gender, etc. patient's primary language should also be recorded here
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Biographic data
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These are example of title B in the health history ; patient herself who seems reliable, patient's son, John, who seems reliable, Mrs. R. Fuentes, interpreter for Theresa Castillo who does not speak English
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Source of History
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What is the significance of Past Medical History?
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Past health events may have residual effects on the current health state. Also, the previous experience with illness may give clues as to how the person responds to illness and to the significance of illness for him or her
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What is the significance of Family history ?
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This data may have genetic significance for the patient and provide you with the person's prolonged contact with any communicable disease or the effect of a family member's illness on this person
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What is the significance of the review of systems?
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To evaluate the past and present health state of each body system, to double check in case any significant data were admitted in the present illness section, and to evaluate health promotion practices
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What is the significance of functional assessment? (ADLs)
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Measures a person's self care ability in the areas of general physical health or absence of illness. (ability to do ADLs)
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