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Glossary of Med-Surg Nursing - 03

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auscultation
listening to sounds produced by the body to assess normal conditions and deviations from normal
branching (regional) examination
a detailed assessment of a particular body system
database
all the health information about a patient
functional health patterns
organizational models used to identify patient strengths in function and to determine if dysfunctional health patterns and/or potential dysfunctional health patterns exist
general survey statement
a statement of the provider's general impression of a patient, including behavioral observations
inspection
the visual examination of a part or region of the body to assess normal conditions or deviations from normal
medical history
a standard format designed to collect data to be used primarily by the physician to determine risk for disease and to diagnose a medical condition
negative finding
the absence of a symptom or sign usually associated with a problem
nursing history
information obtained that is used to determine what responses a patient is exhibiting or could potentially exhibit as a result of a health problem
objective data
data that can be observed and measured
palpation
the examination of the body through the use of touch
percussion
an assessment technique involving the production of sound to obtain information about the underlying area
physical examination
the systematic assessment of the physical and mental status of a patient
positive finding
indication that the patient has or had the particular problem, sign, or symptom under discussion
screening physical examination
an examination performed for screening situations, health surveillance, and health maintenance purposes
subjective data
data collected by interviewing the patient during the nursing history; includes information that can be described or verified only by the patient

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