Nursing data collection, documentation, and analysis – Flashcards

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nursing
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diagnosis and treatment of human responses based on accurate client assessments to promote health and prevent illness and injury
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nursing process
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assessment, diagnosis, planning, implementation, evaluation
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assessment
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collecting subjective and objective data, phase 1
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diagnosis
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analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, or referral), phase 2
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planning
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determining outcome criteria and developing a plan, phase 3
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implementation
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carrying out the plan, phase 4
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evaluation
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assessing whether the outcome criteria have been met and revising the plan as necessary, phase 5
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initial comprehensive assessment
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subjective and objective data regarding functional health and body systems (health history and physical assessment)
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ongoing or partial assessment
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data collection that occurs after the comprehensive database is established, reassessment or follow-up
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focused assessement
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a thorough assessment of a particular client problem and does not cover areas not related to the problem
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emergency assessment
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a rapid assessment performed in life-threatening situations
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subjective data
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information that can be elicited or verified only by the client
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objective data
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all measurable and observable pieces of information about a client and his or her overall state of health (inspection, palpation, auscultation, percussion
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health assessment
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collecting subjective data, collecting objective data, validation of data, documentation of data
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