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 - ASS...
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.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Topskills. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for £11.25. You're not tied to anything after your purchase.
