Exam 1 Physical Examination and Health
Assessment
ASSESSMENT—POINT OF ENTRY IN AN ONGOING PROCESS - Assessment is the
collection of data about the individual's health state
subjective data
objective data
database
Diagnostic Reasoning - is the process of analyzing health data and drawing conclusions
to identify diagnoses.
nursing process - ASSESSMENT
DIAGNOSIS
OUTCOME IDENTIFICATION
PLANNING
IMPLEMENTATION
EVALUATION
ASSESSMENT - Collect data: Review of the clinical record
Health history
physical examination
functional assessment
Risk assessment
Review of the literature
Use evidence-based assessment techniques
Document relevant data
DIAGNOSIS - Compare clinical findings with lormal and abnormal variation and
developmental events
Interpret data Identify clusters of clues, Make hypotheses, Test hypotheses, Derive
diagnoses
Validate diagnoses
Document diagnoses
, OUTCOME IDENTIFICATION - Identify expected outcomes Individualize to the person
Identify expected culturally appropriate outcomes
•Establish realistic and measurable outcomes
Develop a timeline
PLANNING - •Establish priorities
Develop outcomes
Set timelines for outcomes
Identify interventions
Integrate evidence-based trends and research
. Document plan of care
IMPLEMENTATION - Implement in a safe and timely manner
• Use evidence-based interventions
• Collaborate with colleagues
•Use community resources
•Coordinate care delivery
Provide health teaching and health promotion
•Document implementation and any modification
principles of Setting Priorities - .Complete a health history, including allergies,
medications, current medical problems, and reason for visit.
Determine whether any problems are related, and set priorities.
Steps to Setting Priorities - • Assign high priority to first-level priority - airway, breathing,
and circulation.
Next attend to second-level priority problems, which include mental status changes,
acute pain, infection risk abnormal laboratory values, and elimination problems.
Assessment
ASSESSMENT—POINT OF ENTRY IN AN ONGOING PROCESS - Assessment is the
collection of data about the individual's health state
subjective data
objective data
database
Diagnostic Reasoning - is the process of analyzing health data and drawing conclusions
to identify diagnoses.
nursing process - ASSESSMENT
DIAGNOSIS
OUTCOME IDENTIFICATION
PLANNING
IMPLEMENTATION
EVALUATION
ASSESSMENT - Collect data: Review of the clinical record
Health history
physical examination
functional assessment
Risk assessment
Review of the literature
Use evidence-based assessment techniques
Document relevant data
DIAGNOSIS - Compare clinical findings with lormal and abnormal variation and
developmental events
Interpret data Identify clusters of clues, Make hypotheses, Test hypotheses, Derive
diagnoses
Validate diagnoses
Document diagnoses
, OUTCOME IDENTIFICATION - Identify expected outcomes Individualize to the person
Identify expected culturally appropriate outcomes
•Establish realistic and measurable outcomes
Develop a timeline
PLANNING - •Establish priorities
Develop outcomes
Set timelines for outcomes
Identify interventions
Integrate evidence-based trends and research
. Document plan of care
IMPLEMENTATION - Implement in a safe and timely manner
• Use evidence-based interventions
• Collaborate with colleagues
•Use community resources
•Coordinate care delivery
Provide health teaching and health promotion
•Document implementation and any modification
principles of Setting Priorities - .Complete a health history, including allergies,
medications, current medical problems, and reason for visit.
Determine whether any problems are related, and set priorities.
Steps to Setting Priorities - • Assign high priority to first-level priority - airway, breathing,
and circulation.
Next attend to second-level priority problems, which include mental status changes,
acute pain, infection risk abnormal laboratory values, and elimination problems.
