module 1: assessing Flashcards
primary source of information
the patient
initial/comprehensive assessment
performed shortly after admittance to health care facility; establishes a complete database for problem identification and care planning; in depth, ask specific and open ended questions
focused assessment
focuses on a specific problem; can be during an initial assessment or on its own as ongoing data collection
quick priority assessment (QPA)
short, focused, prioritized assessments completed to gain the most important information first; look for red flags and identify if pt. needs to be in isolation or on percautions
emergency assessment
performed when a physiologic or psychological crisis presents; identify life threatening problems
time lapsed/ongoing assessment
compare pt. current status to baseline data; rehab pt. to make necessary revisions in care plan; not done in response to a complaint
triage assessment
screening assessment to determine the extent and severity of pt. problems and recommend appropriate follow up; general surveillance questions to determine the pts. next actions; done in person or over the phone
objective data
observable and measurable data; can be verified by another person
subjective data
information perceived only by the affected person; ex. pain, HA, dizziness
nursing history
general information that is used to identify strengths, weaknesses, and potential health risks/problems; includes the patient interview
inspection
observation using senses; begins before even touching patient, ongoing throughout health history and physical exam
cardinal rules of palpation
warm hands, palpate light-deep, rough area that hurts last
light palpation
1 cm (0.5in)
deep palpation
2 cm (1 in)
moderate palpation
1-2 cm (0.5-0.75 in)
