Term
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Definition
| a professional nurse's approach to identify, diagnose, and treat human responses to health and illness |
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Term
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Definition
includes 2 steps: 1. collection and verification of data from a primary source (the client) and secondary sources (e.g., family, health professionals, and medical record)
2. the analysis of all data as a basis for developing nursing diagnosis, identifying collaborative problems, and developing a plan of individualized care |
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Term
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Definition
| includes active listening prompts such as "all right" and "uh-huh". encourages client to give more details. |
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Term
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Definition
| information you acquire through the use of the senses |
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Definition
| involves recognizing patterns or trends in the clustered data, comparing them with standards, and then coming to a reasoned conclusion about the client's responses to a health problem |
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Term
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Definition
| organized conversation with the client |
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Definition
| includes data about the client's current level of wellness, including a review of body systems, family and health history, spiritual health, and mental and emotional reactions to illness |
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Term
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Definition
| observations or measurements of a client's health status |
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Definition
| your client's verbal descriptions of their health problems |
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Term
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Definition
| systematic method for collecting data on all body systems |
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Term
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Definition
| the comparison of assessment data with another source to determine data accuracy |
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