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ABC framework
a system that uses letters as reminders to establish three fundamental priorities during a nursing assessment: airway, breathing, and circulation
actual problem
current health issues that are identifiable through symptoms or clinical evidence
analyzing
the systematic examination and evaluation of information, data, or evidence to derive meaning, identify patterns, and draw conclusions
applying
the practical implementation of knowledge, skills, and strategies to address clinical challenges, solve problems, and make informed decisions in healthcare settings
assessment
the systematic and dynamic process of collecting and analyzing data about a patient’s health
auscultation
the technique of listening to the sounds produced within the body, typically using a stethoscope
Beck Depression Inventory
a widely used self-report questionnaire designed to assess the severity of depression symptoms experienced by an individual
clinical judgment
utilizing nursing knowledge, critical thinking, and clinical reasoning, drawing from evidence, theories, and interdisciplinary insights to make informed and patient-centered decisions
Clinical Judgment Measurement Model (CJMM)
the latest framework developed by the National Council of State Boards of Nursing (NCSBN) to aid in identifying nursing-focused clinical problems
clinical reasoning
the process by which a healthcare provider combines their own knowledge and experience with data obtained through various patient assessments to diagnose a medical problem and determine an appropriate response
conceptualizing
forming an initial understanding of the patient’s situation based on the data collected
critical thinking
the disciplined, systematic process of applying skillful reasoning as a guide to belief or action
data
information that nurses gather about a patient’s health status
deductive reasoning
the process of applying general principles to draw conclusions about specific cases
emergency assessment
an assessment conducted when a patient presents with life-threatening or potentially life-threatening conditions
Faith, Importance and Influence, Community, and Address (FICA) tool
a tool used by healthcare professionals to assess patients’ spiritual and religious beliefs and practices
Holmes-Rahe Life Stress Inventory
a tool used to measure the stress level experienced by an individual based on the occurrence of certain life events within a specified period
inductive reasoning
the process of making generalizations based on specific observations
initial assessment
the first extensive evaluation of a patient’s overall health status, including their physical condition, medical history, and current symptoms; typically conducted on a patient's admission to a healthcare facility
inspection
a fundamental nursing skill by which the nurse visually examines the patient’s body for normal and abnormal findings
objective data
measurable and observable information collected by the healthcare provider
ongoing assessment
assessment conducted continuously, often in response to changes in the patient’s condition
percussion
the technique of assessing the body’s underlying structures based on the sound they make when tapped
physiological crisis
a critical situation where the patient’s physiological functions are severely compromised, posing an immediate threat to life or health
potential problem
risk or condition that a patient is susceptible to but not currently manifesting symptoms of
primary data
information provided directly by the patient
problem-focused assessment
a targeted examination conducted to assess a specific health issue or symptom identified in a patient
psychological crisis
a state of acute emotional or mental distress that significantly impairs an individual’s ability to cope with their current circumstances
secondary data
information collected from a family member, chart, or other source
subjective data
descriptions provided by the patient or family members of the patient’s symptoms, feelings, and perceptions
synthesizing
the process of integrating, combining, or organizing diverse pieces of information, data, or evidence to develop a coherent understanding, formulate hypotheses, or generate solutions
time-lapsed assessment
an assessment conducted when several months have passed since the previous assessment to evaluate the progress of a patient’s health over time
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