Nursing Assessment and Diagnosis Flashcards

Vocabulary flashcards covering nursing assessment types, data collection methods, and the principles of clinical diagnosis based on Chapters 15 and 16.

Assessment

The systematic and continuous collection, analysis, validation, and communication of patient data.

Comprehensive Initial Assessment

Performed shortly after hospital admittance to establish a complete database for problem identification and care planning by collecting data on all health aspects.

Focused Assessment

Performed to gather data about a specific problem already identified, or to identify new or overlooked problems; can be routine ongoing data collection.

Quick Priority Assessments

Short, focused, prioritized assessments completed to gain the most important information needed first and flag existing problems.

Emergency Assessment

Performed when a physiologic or psychological crisis presents to identify and gather data about life-threatening problems.

Time-Lapsed Assessment

An assessment performed to compare a patientʼs current status to baseline data obtained earlier to reassess health status.

Triage Assessment

A screening assessment conducted on the phone or in person to determine the extent and severity of patient problems and recommend follow-up.

Medical Assessment

Assessments that target data pointing to pathologic conditions.

Nursing Assessment

Assessments focusing on the patientʼs response to health problems.

Objective Data

Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them, such as skin moisture or vomiting.

Subjective Data

Information perceived only by the affected person, such as the pain experience, feeling dizzy, or feeling anxious.

Nursing History

A record obtained by interviewing the patient that captures specific details like usual health habits, cultural considerations, and expectations of nursing.

Nursing Interview Phases

The four stages of a nursing interview: Preparatory phase, Introduction, Working phase, and Termination.

Inspection

The assessment method involving the process of performing deliberate, purposeful observations in a systematic manner.

Palpation

The use of the sense of touch to assess skin temperature, turgor, texture, moisture, and vibrations within the body.

Percussion

The act of striking one object against another to produce sound.

Auscultation

The act of listening with a stethoscope to sounds produced within the body.

Diagnosing

The step where the nurse interprets and analyzes patient data, identifies strengths and health problems, and formulates nursing diagnoses.

Nursing Diagnosis

Describes patient problems that nurses can treat independently.

Medical Diagnosis

Identifies diseases and describes problems for which the physical or advanced practice nurse directs the primary treatment.

Collaborative Problems

Health issues managed by using both physician-prescribed and nursing-prescribed interventions.

PPMP (Predict, Prevent, Manage, and Promote)

A framework to predict complications, manage risk factors, ensure safety, and promote optimum function.

Problem Statement

A part of the nursing diagnosis that identifies what is unhealthy about the patient and indicates the need for change.

Etiology

The component of a nursing diagnosis that identifies the factors that are maintaining an unhealthy state or causing health problems.

Defining Characteristics

The subjective and objective data (cues) that signal the existence of the patient's health problem.