lesson 001 Flashcards
is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity
health
it focuses on both health history and physical examination. it is used to evaluate the overall status of an individual.
nursing health assessment
is the systematic and continuous collection, organization, validation, and documentation of information. it is the process by which the nurse and patient identify the needs and concerns together
assessment
a type of data that only can be described by the patient, said
subjective
a type of data that can be observed or measured
objective
what do you call the source of data if it is from the patient
primary source
what do you call the source of data if it is from a family member, friends, significant others, patient’s record, or health team members
secondary source
when the signs or symptom started
onset
where the sign or symptom started
location
how long the sign and symptom has been going on
duration
what the symptom feels like, how it is described, and the severity
characteristics
what else accompanies the sign and symptom
associated manifestation
anything that the patient has tried to relieve the sign or symptom
relieving factors
any interventions the patient has previously tried
treatment
