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• Assessment


  The systematic and continuous collection, organization, validation, and documentation of data
• Initial assessment


  Performed within specified time after admission to a healthcare agency
• Problem-focused assessment


  Ongoing process integrated with nursing care
• Emergency assessment


  Performed during any physiologic or psychologic crisis of the client
• Time-lapsed reassessment


  Performed several months after initial assessment
• Comprehensive Assessment


  Performed upon admission, includes a complete health history
• Focused assessment


  Focused on a particular need or healthcare problem
• Ongoing assessment


  Systematic monitoring & observation related to specific problems
• Collecting Data


  The process of gathering information about a client's health status
• Database


  Contains all the information about a client
• Subjective data


  Symptoms that can be described or verified only by that individual
• Objective data


  Signs that can be observed or can be measured or tested against an accepted standard
• Types of data


  • Constant data
  • Variable data
• Constant data


  Information that does not change over time such as race, blood type
• Variable data


  Data that can change quickly, frequently, or rarely such as blood pressure, level of pain, age