health assessment pt. 2 Flashcards
Also referred to as nursing health history, nursing assessment
or database form
ORGANIZING DATA
assessment formats (cfwn)
Conceptual Models or
Frameworks
wellness models
non-nursing models
(assessment format)
Gordon’s Functional Health Patterns
Orem’s Self-Care Model
Roy’s Adaptation Model
Conceptual Models or
Frameworks
(assessment format)
Includes factors and attitudes that
influence levels of wellness
wellness models
(assessment format)
Body Systems Model
Maslow’s Hierarchy of Needs
Developmental Theories
non-nursing models
The act of “double-checking” or verifying
data to confirm that it is complete,
factual and accurate.
validating data
subjective or
objective data that can
be directly observed by
the nurse
cues
nurse’s
interpretation or
conclusions made
based on the cues
inferences
Not all data requires
validation. (e.g. ?)
e.g. height,
weight, lab studies
The nurse validates data
when there are
? between
data obtained in the
? and ?.
discrepancies, interview and physical assessment
Nurses need to be ?
of their own biases,
values and beliefs and to
separate ? from ?, interpretation
and assumptions.
aware, fact from
inference
To build an accurate
database, nurses must
? assumptions
regarding client’s ? or ? behavior.
validate, physical
or emotional
(type of documentation) oral, written or computer-based communication intended to
convey information to others
report
(type of documentation) also called chart or client record; a formal legal document that
provides evidence of client’s care; can be written or computer based
record
The process of making an entry on a client record is called?
recording,
charting or documenting.
Nurse is ? and should document according to organization
policies and universal standards
accountable
Data are recorded in a factual manner
and not ? by the nurse.
interpreted
what is not documented
is ? ?
not done
