Assessing
Observable and measurable information that can be seen,heard or felt by someone
What is Objective data?
A nurse recognized an unhealthy situation developing with her patient. The patient cries all night and sleeps all-day
What is recognizing data and clusters
A care plan that is developed by the nurse who performs the initial nursing history and physical assessment
What is Initial Care plan?
the nurse documents a diabetic patients intake and output of fluids on this
What is fluid intake and output record?
The conscious and deliberate use of the 5 senses to gather information
What is Observation?
A group of patient data or cues that point to the existence of a patient problem
What is a data cluster?
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The purpose of this type of planning is to keep the care plan up to date
What is on going problem solving care plan?
The nurse uses this form to record a patient BP.pulse, temp, respirations
What is a graphic record?
A planned communication to obtain data
What is an interview?
Risk for decreased cardiac output is an example of this
What is a nursing diagnosis?
This type of plan is done when a patient is discharged from an institution and is best prepared by the nurse that worked closely with the patient
What is discharge care plan?
tHE NURSE RECORDS THE DATABASE OBTAINED FROM THE NURSING HISTORY AND PHYSICAL ASSESSMENT HERE
What is an initial nursing assessment?
The gathering of data about a specific problem that has been identified
What is a focused assessment?
The patient complains of chills, dizziness, and nausea what type of data is this
What is Subjective data?
Prepared care plans that identify the nursing diagnosis, outcomes, and related nursing intervention common to specific populations or health problems
What is a standardized care plan?
The nurse documents that she gave morphine 4 mg IVP at 1600 here
What is the medication record (MAR)?
The examination of a patient for objective data that may better define a patient's condition
Physical assessment
A persistent systolic blood pressure of over 140 mmHg and diastolic BP of 90 mm hg, or current use of hypertensive medications medications
What is hypetension?
This is a diagram of patient problems and interventions and is used to organize data, analyze data, and take a holistic view of the patient situation
What is a concept map ?
The nurse summarizes the patient's reason for treatment, significant findings, procedure performed and treatments ordered, and any other specific instruction here
What is the discharge and transfer summary ?