Taylor Chapter 15: Assessing

assess

to systematically and continuously collect, validate, and communicate patient data

cue

significant information that is helpful in making decisions

data

information

database

all the pertinent patient information that enables a comprehensive and effective plan of care to be designed and implemented

emergency assessment

type of rapid focused assessment conducted when addressing a life-threatening or unstable situation

focused assessment

assessment is conducted to assess a specific problem; focuses on pertinent history and body regions but may also be used to address the immediate and highest priority concerns for an individual patient

inference

the judgment reached about a cue

initial assessment

comprehensive nursing assessment resulting in baseline data that enable the nurse to make a judgment about a patient's health status, ability to manage one's own health care, and need for nursing, and to plan individualized, holistic health care for the patient

interview

planned communication for a specific purpose (e.g., data collection)

minimum data set

a standard established by health care institutions that specifies the information that must be collected from every patient

nursing history

assessment of the patient by interview to identify the patient's health status, strengths, health problems, health risks, and need for nursing care

objective data

information perceptible to the senses; may be verified by another person

observation

conscious and deliberate use of the five senses to gather data

patient-centered assessment method (PCAM)

tool for assessing patient complexity using the social determinants of health that often explain why patients with the same or similar health conditions differ in their ability to manage their health and in their outcomes

physical assessment

systematic examination of the patient for objective data to better define the patient's condition and to help the nurse in planning care, usually performed in a head-to-toe format; a collection of objective data about changes in the patient's body systems

quick priority assessments (QPAs)

short, focused, prioritized assessments you do to gain the most important patient information you need to have first.

review of systems (ROS)

physical examination of all body systems in a systematic manner as part of the nursing assessment

subjective data

(symptoms, covert data) information perceived only by the affected person

time-lapsed assessment

an assessment that is scheduled to compare a patient's current status to baseline data obtained earlier

triage

quickly examining patients to determine the extent and severity of problems and recommending appropriate treatment.

validation

act of confirming or verifying