SoU Physical Assessment Chapters 1-4

what a person says about himself or herself

What you as a health professional observe (by inspecting, percussing, palpating, and auscultating during the physical examination)

the process of analyzing health data and drawing conclusions to identify diagnoses

• 1. Attending to initially available cues
• 2. Formulating diagnostic hypotheses
• 3. gathering data relative to the tentative hypothesis
• 4. evaluating each hypothesis with the new data collected thus arriving at a final diagnosis

• Assessment
• Diagnosis
• Outcome Identification
• Planning
• Implementation
• Evaluation

AD o PIE (A delicious orange PIE)

a means by which we learn to assess and modify, if indicated, before acting.

emergent, life threatening

• Remember: ABC plus V
• Airway
• Breathing
• Cardiac/circulation problems
• Vital sign concerns

• those requiring your prompt intervention to forestall further deterioration, for example:
• mental status change,
• acute pain,
• acute urinary elimination problems, untreated medical problems,
• abnormal values,
• risks of infections,
• or risk to safety or security.

those that are important to patients health but can be addressed after more urgent health problems are addressed.

problems with lack of knowledge, rest, activity, or family coping

those in which the approach to treatment involves multiple disciplines.

certain psychologic complications in which nurses have the primary responsibility to diagnose the onset and monitor the changes in status

• Complete
• Focused or problem centered
• Follow-up
• & Emergency

Consideration of the whole person

• Legal resident
• Naturalization
• Non-Immigrant
• Parolee
• Permanent Resident Alien
• Refugee

care that results in positive outcomes and satisfaction for the patient

care that takes into consideration the values, preferences, and expressed needs of the patient

a set of congruent behaviors, attitudes, and policies that come together in a system among professionals that enables work in cross-cultural situations

Title VI of the Civil Rights Act of 1964

the unusual and disproportionate frequency of a given health problem within a population when compared with other populations.

the balance of a person both within ones being and in the outside world as a complex, and interrelated phenomenon

Pain

• R ealize
• E xamine
• S elect
• P ace
• E ncourage
• C heck
• T ough

it collects objective and subjective data to help identify and evaluate problems and develop a plan of care

foundation, nursing process

record a summary of the physical-assessment data, system by system

ensures that patient information is kept confidential and gives patients more control over their personal healthcare information and who has access to it.