Lewis Medical-Surgical Nursing Chapter 3 _ Health History
Lewis
& Physical
Medical-Surgical
Page
Examination
1 of 26
Nursing
2026_2027.pdf
Chapter 3 _ Health History & Physical Examination 2026_2027
Lewis Medical-Surgical Nursing
Chapter 3 | Health History & Physical
Examination 2026/2027
Lewis Medical-Surgical Nursing Chapter 3 _ Health History
Lewis
& Physical
Medical-Surgical
Page
Examination
1 of 26
Nursing
2026_2027.pdf
Chapter 3 _ Health History & Physical Examination 2026_2027
,Lewis Medical- Surgical Nursing_Health History and Physical Examination- Chapter 3.pdf Page 2 of 26 Lewis Medical- Surgical Nursing_Health History and Physical Examination- Chapter 3
Conceptual Focus
The interprofessional team, also known as an interdisciplinary, transdisciplinary, or
multidisciplinary team, is made up of a number of health care professionals who provide
care to a patient.
The findings of your nursing assessment (1) contribute to a database that identifies the
patient's current and past health status and (2) provide a baseline against which future
changes can be evaluated. The purpose of the nursing assessment is to enable you to make
clinical judgments about your patient's health status.
Assessment is the first step of the nursing process. It is performed continually throughout
the nursing process to validate nursing diagnoses, evaluate nursing interventions, and
determine whether patient outcomes and goals have been met.
Assessment describes a hands-on data collection process and a database identifies a
specific list of information (data) to collect.
Lewis Medical- Surgical Nursing_Health History and Physical Examination- Chapter 3.pdf Page 2 of 26 Lewis Medical- Surgical Nursing_Health History and Physical Examination- Chapter 3
, Lewis Medical- Surgical Nursing_Health History and Physical Examination- Chapter 3.pdf Page 3 of 26 Lewis Medical- Surgical Nursing_Health History and Physical Examination- Chapter 3
Data Collection
The database is all the health information about a patient. It includes
(1) nursing history and physical examination,
(2) the medical history and physical examination, and (3) laboratory and diagnostic test
results.
A nurse and health care provider (HCP) perform a patient history and a physical examination
using formats and data based on each discipline's focus
Lewis Medical- Surgical Nursing_Health History and Physical Examination- Chapter 3.pdf Page 3 of 26 Lewis Medical- Surgical Nursing_Health History and Physical Examination- Chapter 3
Lewis
& Physical
Medical-Surgical
Page
Examination
1 of 26
Nursing
2026_2027.pdf
Chapter 3 _ Health History & Physical Examination 2026_2027
Lewis Medical-Surgical Nursing
Chapter 3 | Health History & Physical
Examination 2026/2027
Lewis Medical-Surgical Nursing Chapter 3 _ Health History
Lewis
& Physical
Medical-Surgical
Page
Examination
1 of 26
Nursing
2026_2027.pdf
Chapter 3 _ Health History & Physical Examination 2026_2027
,Lewis Medical- Surgical Nursing_Health History and Physical Examination- Chapter 3.pdf Page 2 of 26 Lewis Medical- Surgical Nursing_Health History and Physical Examination- Chapter 3
Conceptual Focus
The interprofessional team, also known as an interdisciplinary, transdisciplinary, or
multidisciplinary team, is made up of a number of health care professionals who provide
care to a patient.
The findings of your nursing assessment (1) contribute to a database that identifies the
patient's current and past health status and (2) provide a baseline against which future
changes can be evaluated. The purpose of the nursing assessment is to enable you to make
clinical judgments about your patient's health status.
Assessment is the first step of the nursing process. It is performed continually throughout
the nursing process to validate nursing diagnoses, evaluate nursing interventions, and
determine whether patient outcomes and goals have been met.
Assessment describes a hands-on data collection process and a database identifies a
specific list of information (data) to collect.
Lewis Medical- Surgical Nursing_Health History and Physical Examination- Chapter 3.pdf Page 2 of 26 Lewis Medical- Surgical Nursing_Health History and Physical Examination- Chapter 3
, Lewis Medical- Surgical Nursing_Health History and Physical Examination- Chapter 3.pdf Page 3 of 26 Lewis Medical- Surgical Nursing_Health History and Physical Examination- Chapter 3
Data Collection
The database is all the health information about a patient. It includes
(1) nursing history and physical examination,
(2) the medical history and physical examination, and (3) laboratory and diagnostic test
results.
A nurse and health care provider (HCP) perform a patient history and a physical examination
using formats and data based on each discipline's focus
Lewis Medical- Surgical Nursing_Health History and Physical Examination- Chapter 3.pdf Page 3 of 26 Lewis Medical- Surgical Nursing_Health History and Physical Examination- Chapter 3
