Term
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Definition
| to systematically and continuously collect, validate, and communicate patient data |
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Definition
| significant information that is helpful in making decisions |
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Definition
| all the pertinent patient information that enables a comprehensive and effective plan of care to be designed and implemented |
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Definition
| rapid focused assessment conducted to determine potentially fatal situations |
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Definition
| assessment conducted to assess a specific problem; focuses on pertinent history and body regions |
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Definition
| the judgement reached about a cue |
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Term
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Definition
| comprehensive nursing assessment resulting in baseline data that enables the nurse to make a judgment about a patient's health status, ability to manage his or her own healthcare, and need for nursing, and to plan individualized, holistic healthcare for the patient |
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Term
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Definition
| planned communication for a specific purpose |
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Definition
| a standard established by healthcare institutions that specifies the information that must be collected from every patient |
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Term
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Definition
| assessment of the patient by interview to identify the patient's health status, strengths, health problems, health risks, and need for nursing care |
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Definition
| information perceptible to the senses; may be verified by another person |
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Term
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Definition
| conscious and deliberate use of the five senses to gather data |
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Term
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Definition
| 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 |
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Term
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Definition
| physical examination of all body systems in a systematic manner as part of the nursing assessment |
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Definition
| information perceived only by the affected person |
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Term
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Definition
| an assessment that is scheduled to compare a patient's current status to baseline data obtained earlier |
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Term
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Definition
| act of confirming or verifying |
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