Chapter 11: Assessing: Vocabulary

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UNIT III: Person-Centered Care and the Nursing Process Chapter 11: Assessing
Alexandra Bozan
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Alexandra Bozan
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Characteristics of Nursing Assessments Purposeful, Prioritized, Systematic, Complete, Factual and accurate, Relevant, Recorded in a standard manner
Different types of nursing assessments comprehensive initial assessment, focused assessment, quick priority assessments, emergency assessment and time-lapsed assessment
initial assessment performed shortly after the patient is admitted
focused assessment gathers data about a specific problem that has already been identified; may be done during the initial assessment; part of ongoing data collection; identifies new or overlooked problems
quick priority assessment short, focused, prioritized, done to gain the most important information you need to have first; can flag existing problems and risks
time-lapsed assessment scheduled to compare a patient's current status to the baseline data obtained earlier
minimum data set specifies the information that must be collected from every patient and uses a structured assessment form to organize or cluster this data
subjective data perceived only by the affected person; called symptoms or covert data
objective data observable and measurable data that can be seen, heard, felt or measured; also called signs or overt data
interview occurs in 4 phases: preparatory phase, introduction, working phase and termination
review of systems (ROS) examination of all body systems, in a systematic manner, commonly using a head-to-toe format
4 methods use to collect data during the physical assessment inspection, palpation, percussion and auscultation
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