What patient says about himself or herself during history taking; symptoms
objective data
what the nurse observes during assessment; signs; can be measured or tested
primary source of data
subjective or objective data collected from the PATIENT themselves
secondary source of data
subjective or objective data collected from something other than the patient
themselves; ex. include family members, medical records
initial assessment
done after admission to provide a complete database for identification of problem,
reference and comparison in the future
problem-focused assessment
ongoing process combined w/ patient care to identify status of a specific problem
identified earlier in assessment
emergency assessment
done during patient crisis to identify life-threatening problems
, time-lapsed assessment
done several months after initial assessment to compare patient's status to the baseline
data previously obtained
3 elements of comprehensive planning
initial, ongoing, discharge
initial planning
developed on admission, comprehensive plan
ongoing planning
carried throughout provision of care; modification of initial plan and keeps plan up to
date
discharge planning
anticipation and planning for needs; begins when the patient is admitted for treatment
goal of planning
broad expectation that results from the interventions; short term and long term
desired outcome (outcome criteria)
a specific expectation from the nursing intervention in the client care plan
SMART goals
Specific, Measurable, Attainable, Realistic, Time oriented
Maslow's Hierarchy of Needs
Physiological
Safety
Love/belonging
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