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Assessment

TermDefinition
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