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Assessment
| Term | Definition |
|---|---|
| Assessment | Collect, organize, validate, and document patient data |
| Diagnosing | Analyze and synthesize data |
| Planning | Determine how to prevent, reduce, and resolve client problems |
| Implementing | Perform planned nursing interventions, reassessment of the patient and documentation |
| Evaluation | Measure the degree to which goals have been achieved |
| Initial Assessment | Done during admission; establish a database and baseline |
| Problem Focused | Determines status of specific problem, specific things, related to problem such as patient complaining of abdominal pain |
| Emergency | Identify what life threat there is and new problems(car accident, suicide attempt) |
| Time Elapsed | Reassess when conditions change, such as ICU, reassess every 4 hours |
| Inspection | Use olfactory and auditory senses to assess moisture, color, texture, shape, position, size and symmetry |
| Palpation | Use pads of fingers to palpate. Assess texture, temperature, vibration, distention, pulsation, tenderness or pain, position size and mobility of organs. |
Created by:
HeatherP
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