Med-Surg Nursing - 03
Terms
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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