Ch 1-5 Flashcards
Signs
Objective data observed, felt, heard, or measured
Symptoms
subjective data perceived and reported by the patient
Subjective Data
data collected from sources other than the nurse’s observations
Objective Data
data that can be measured through physical exam, observation, or diagnostic testing
Primary Source Data
subjective data acquired directly from a patient
Secondary Source Data
data acquired from another individual (not patient)
Clinical Manifestation
used to describe the presenting signs and symptoms experienced by a patient
Comprehensive Assessment
involves a detailed history and physical exam performed at the onset of care in a primary care setting or an admission to a hospital or ltc facility; encompasses health problems experienced by the patient, health promotion, disease prevention, and assessment for problems associated with known risk factors, or assessment for age and gender-specific health problems
Problem-based/ Focused Assessment
involves a history and physical exam that is limited to a specific problem or complaint; commonly used in a walk-in clinic or ED, but it may also be applied in other outpatient settings
Episodic/ Follow-up Assessment
usually done when a patient is following up with health care provider for a previously identified problem
Shift Assessment
when individuals are hospitalized, nurses conduct assessments each shift; identify changes to a patient’s condition from the baseline
Screening Assessment
short exam focused on disease detection
Clinical Judgement
an interpretation or conclusion about a patient’s needs, concerns, or health problems and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate
Health Promotion
behavior motivated by the desire to increase well-being and actualize human health potential
Health Protection
behavior motivated by the desire to actively avoid illness, detect it early, or maintain functioning within its constraints
Primary Prevention
to prevent a disease from developing through promotion of healthy lifestyles
Secondary Prevention
screening efforts to promote the early detection of disease
Tertiary Prevention
minimizing the disability from acute or chronic disease or injury and helping the patient to maximize his or her health
The Nursing Process (A-D-O-P-I-E)
Assessment
Diagnosis
Outcome identification
Planning
Implementation
Evaluation
Standard Precautions
precautions applied in all aspects of patient care and in all health settings
Transmission-Based Precautions
guidelines designed for the control of infections among patients with known or suspected infections caused by certain pathogens of epidemiologic significance
Inspection
data obtained by a visual exam of the body, including body movement and posture, as well as that obtained by smell
Palpation
using the hands to feel texture, size, shape, consistency, pulsation, and location of certain parts of the patient’s body
Percussion
performed to evaluate the size, borders, and consistency of internal organs; detect tenderness; and determine the extent of fluid in a body cavity (direct or indirect)
