NSG 3133 Physical Assessment Exam 1
health history ANSa collection of subjective data that provides information about the patient's current
health status
physical examination ANSa collection of objective data using a series of techniques
nursing process ANS1- assessment
2- diagnosis
3- planning
4- implementation
5- evaluation
plan of care ANS1- collect health history
2- perform physical examination
3- document data
4- analyze interpret data
5- develop treatment
signs ANSobjective data observed, felt, heard, or measured
symptoms ANSsubjective data perceived and reported by client
assessment ANSwhen the nurse collects pertinent data and information relative to the health care
consumer's health
diagnosis ANSwhen the nurse analyze the assessment data to determine actual or potential diagnosis,
problems, or issues
, planning ANSwhen the nurse develops a plan that prescribes strategies to attain expected, measurable
outcomes
implementation ANSwhen the nurse carries out identified plan; coordinates care delivery
evaluation ANSwhen the nurse assess progress toward attainment of goals and outcomes
establish baseline ANSwhy is documentation of data important?
comprehensive ANShealth assessment involving a detailed history and physical examination at the onset
of care
- health promotion
- disease prevention
- assessment for problems associated with known risk factors
problem based ANShealth assessment limited to a specific problem or complaint
- commonly used in walk-in clinic or emergency
episodic ANShealth assessment following up with previously identified problem
- ongoing condition
- regular visits to the clinic
shift ANShealth assessment done each shift by nurse to determine changes from baseline
screening ANShealth assessment focused on disease detection
- health fair or provider's office
primary ANShealth promotion preventing disease from developing through promoting health lifestyle
health history ANSa collection of subjective data that provides information about the patient's current
health status
physical examination ANSa collection of objective data using a series of techniques
nursing process ANS1- assessment
2- diagnosis
3- planning
4- implementation
5- evaluation
plan of care ANS1- collect health history
2- perform physical examination
3- document data
4- analyze interpret data
5- develop treatment
signs ANSobjective data observed, felt, heard, or measured
symptoms ANSsubjective data perceived and reported by client
assessment ANSwhen the nurse collects pertinent data and information relative to the health care
consumer's health
diagnosis ANSwhen the nurse analyze the assessment data to determine actual or potential diagnosis,
problems, or issues
, planning ANSwhen the nurse develops a plan that prescribes strategies to attain expected, measurable
outcomes
implementation ANSwhen the nurse carries out identified plan; coordinates care delivery
evaluation ANSwhen the nurse assess progress toward attainment of goals and outcomes
establish baseline ANSwhy is documentation of data important?
comprehensive ANShealth assessment involving a detailed history and physical examination at the onset
of care
- health promotion
- disease prevention
- assessment for problems associated with known risk factors
problem based ANShealth assessment limited to a specific problem or complaint
- commonly used in walk-in clinic or emergency
episodic ANShealth assessment following up with previously identified problem
- ongoing condition
- regular visits to the clinic
shift ANShealth assessment done each shift by nurse to determine changes from baseline
screening ANShealth assessment focused on disease detection
- health fair or provider's office
primary ANShealth promotion preventing disease from developing through promoting health lifestyle
