18 notecards = 5 pages (4 cards per page)
is the systematic and continuous collection, analysis, validation, and communication of patient data, or information.
includes all the pertinent patient information collected by the nurse and other health care professionals.
identifies the patient’s health status, strengths, health problems, health risks, and need for nursing care.
is performed shortly after the patient is admitted to a health care agency or service.
the nurse gathers data about a specific problem that has already been identified.
to identify life- threatening problems.
is scheduled to compare a patient’s current status to the baseline data obtained earlier.
minimum data set
that specifies the information that must be collected from every patient and uses a structured assess- ment form to organize or cluster this data.
are information perceived only by the affected person; these data cannot be perceived or verified by another person.
are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them.
is the conscious and deliberate use of the five senses to gather data.
is a planned communication.
is the examination of the patient for objective data that may better define the patient’s condition and help the nurse plan care.
review of systems (ROS)
nursing physical assessment involves the examination of all body systems, called the ______, in a systematic manner, commonly using a head-to-toe format.
that something may be wrong.
judgment you reach about the cue (the patient’s hearing may be impaired on his left side) is an
is the act of confirming or verifying.