Chapter One- Jarvis Health Assessment
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Created by:
ADunn84 on May 10, 2012
Subjects:
Classes:
NURS Assessment, NURS 3510: Health Assessment
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18 terms
Terms | Definitions |
|---|---|
 Subjective data | What the person says about himself/herself during health history taking |
| Objective data | What you observe by inspecting, percussing, palpating, and auscultating during physical examination |
| Nursing process | 6 phases- assessment, diagnosis, outcome identification, planning, implementation, evaluation, assessment |
| Assessment | Collect data about an individual's health state. i.e. Health history, physical examination, risk assessment, review of clinical record, use evidence based techniques |
| Diagnosis | Compare clinical findings with normal and abnormal variation and developmental events, interpret data, document diagnosis |
| Planning | Establish priorities, develop outcomes, set timelines, identify interventions, document plan of care |
| Implementation | Implement in a safe and timely manner, use evidence based interventions, provide health teaching, document implementation and any modification |
| Evaluation | Progress towards outcomes, conduct systematic ongoing criterion based evaluation, include patient and significant others |
| Nursing diagnosis | This is a clinical judgment about individual, family, or community responses to actual or potential health problem/life processes. It provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. |
| 4 types of data based on clinical situation | Complete total health database, focused or problem centered database, follow up database, emergency database |
| Holistic health | the view that the mind, body, and spirit are interdependent and function as a whole within the environment |
| Database | Patients record, laboratory studies, subjective and objective data all together |
| Evidence based practice (EBP) | clinical decision-making that integrates the best available research with clinical expertise and patient characteristics and preferences |
| Complete total health database | Complete health history and physical examination. It describes current and past health state and forms a baseline against which all future changes can be measured. Yields first diagnoses |
| Focused or problem centered database | For limited or short term problem. Collect "mini" database, smaller in scope, concerns mainly one problem, one cue complex, or one body system |
| Follow up database | used in all settings to monitor progress on short-term or chronic health problems |
| Emergency database | rapid collection of the database, usually compiled concurrently with life-saving measures |
| Biomedical model | focus on health; belief that health is the absence of disease |
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