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NSG 3133 Physical Assessment Exam 1

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NSG 3133 Physical Assessment Exam 1 health history - - a collection of subjective data that provides information about the patient's current health status physical examination - - a collection of objective data using a series of techniques nursing process - - 1- assessme

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NSG 3133 Physical Assessment Exam 1
health history - - a collection of subjective data that provides information about the
patient's current health status



physical examination - - a collection of objective data using a series of techniques



nursing process - - 1- assessment
2- diagnosis
3- planning
4- implementation
5- evaluation



plan of care - - 1- collect health history
2- perform physical examination
3- document data
4- analyze interpret data
5- develop treatment



signs - - objective data observed, felt, heard, or measured



symptoms - - subjective data perceived and reported by client



assessment - - when the nurse collects pertinent data and information relative to the
health care consumer's health



diagnosis - - when the nurse analyze the assessment data to determine actual or
potential diagnosis, problems, or issues

,NSG 3133 Physical Assessment Exam 1
planning - - when the nurse develops a plan that prescribes strategies to attain
expected, measurable outcomes



implementation - - when the nurse carries out identified plan; coordinates care
delivery



evaluation - - when the nurse assess progress toward attainment of goals and
outcomes



establish baseline - - why is documentation of data important?



comprehensive - - health 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 - - health assessment limited to a specific problem or complaint

- commonly used in walk-in clinic or emergency



episodic - - health assessment following up with previously identified problem

- ongoing condition
- regular visits to the clinic



shift - - health assessment done each shift by nurse to determine changes from
baseline



screening - - health assessment focused on disease detection

, NSG 3133 Physical Assessment Exam 1
- health fair or provider's office



primary - - health promotion preventing disease from developing through promoting
health lifestyle



secondary - - health promotion screening efforts to promote early detection of
disease



tertiary - - health promotion minimizing severity and disability from disease through
appropriate therapy for chronic disease



clinical judgment - - an interpretation or conclusion about a patient's needs,
concerns, or health problems and/or the decision to take action (or not), use or modify
standard approaches, or improvise new ones as deemed appropriate by the patient's
response.



organize - - after collecting and documenting data, nurses _____ or cluster them so
the problems appear more clearly
-body system format
-conceptual format



pregnancy - - special emphasis on data that may impact _____ outcomes



techniques to enhance - - ______ __ ______the interview:
- active listening
- facilitation
- clarification
- reflection
- confrontation

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