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46 Cards in this Set
- Front
- Back
ASSESSMENT
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Collection of data about an individual's health state
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SUBJECTIVE DATA
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What a person says
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OBJECTIVE DATA
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What you observe from a person
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NURSING PROCESS
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Problem solving approach to clinical judgments
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MEDICAL DIAGNOSIS
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Evaluates cause of disease;Identifies pathology to prescribe treatment
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COMPLETE DATA
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Total Health Assessment
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EPSIODIC DATA
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Problem Centered
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FOLLOW UP
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Assessment following Illness or injury
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EMERGENCY
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Assessment short as possible focusing on life threatening issues
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GROWTH
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Increase in the number and size of cells;measurable
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DEVELOPMENT
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Gradual change & expansion;Individual Adaptation
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CEPHALOCAUDAL
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Head to Tail
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PROXIMODISTAL
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Near to far, midline to periphery
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DIFFERENTIATION
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Simple to complex;gross before fine; generalized before specific
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ERIKSON'S
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Series of conflicts must be resolved for progression
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INFANCY-birth/1 year
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Trust vs. Mistrust
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TODDLER-1to3yo
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Autonomy vs. Shame and doubt
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PRE-SCHOOL;3-6yo
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Initiative vs. Guilt
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SCHOOL-AGE;6-12
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Industry vs. Inferiority
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ADOLESCENCE
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Identity vs. Role Confusion
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YOUNG ADULT
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Intimacy vs. Isolation
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MIDDLE ADULT
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Generativity vs. Stagnation
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LATE ADULTHOOD
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Ego integrity vs. Despair
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PIAGET
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Each persons way of perceiving and processing info
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AUTONOMY VS. SHAME AND DOUBT
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Pursuit of Independance
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INTIMATE ZONE
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0-1.5 feet
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PERSONAL DISTANCE
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1.5-4 ft.
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SOCIAL DISTANCE
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4-12 feet
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PUBLIC DISTANCE
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12+feet
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OPEN-ENDED QUESTIONS
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broadly stated, encouraging a free-flowing response
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CLOSED ENDED
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more direct, specific require 1 or 2 words
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DIRECTIVE
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focus on one set of thoughts
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Permission-giving
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explaining that you have sensitive questions to ask
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Active Listening
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Focusing on what's being said
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Facilitation
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encourage client to continue; "Uh huh"
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Clarification
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obtain more info; "What do you mean by__?"
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Restatement
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Repeating what was said using different words
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Reflection
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repeating what the client says to encourage elaboration
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Confrontation
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used when inconsistencies occur;confusion not accusation
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Interpretation
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share conclusion from data
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Summary
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condenses and orders data
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Empathy
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recognizes feelings
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Explanation
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shares factual information
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NONtherapeutic techniques
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bad;professional terminology, talking too much
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COLDSPA
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character, onset, location, duration, severity, pattern, associated factors
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Mental status/ABCT
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appearance,behavior,cognition, thought processes
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