Exam 1 Physical Examination and Health
Assessment
ASSESSMENT—POINT OF ENTRY IN AN ONGOING PROCESS - ANS Assessment is the collection of data
about the individual's health state
subjective data
objective data
database
Diagnostic Reasoning - ANS is the process of analyzing health data and drawing conclusions to identify
diagnoses.
nursing process - ANS ASSESSMENT
DIAGNOSIS
OUTCOME IDENTIFICATION
PLANNING
IMPLEMENTATION
EVALUATION
ASSESSMENT - ANS 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 - ANS 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 - ANS Identify expected outcomes Individualize to the person
Identify expected culturally appropriate outcomes
•Establish realistic and measurable outcomes
Develop a timeline
PLANNING - ANS •Establish priorities
, Develop outcomes
Set timelines for outcomes
Identify interventions
Integrate evidence-based trends and research
. Document plan of care
IMPLEMENTATION - ANS 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
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