what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination
Health Care Provider Data
Measurable
Observable
Physical Examination
See, feel, touch, and listen
database
patients record, lab results, subjective data, and objective data combined
Diagnostic reasoning
the process of analyzing health data and drawing conclusions to identify diagnoses
nursing process
five-step systematic method for giving patient care; involves assessing, diagnosing, planning, implementing, and evaluating
First-level priority problems
emergent, life-threatening, and immediate, such as establishing an airway or supporting breathing
Second-level priority problems
those that are next in urgency requiring your prompt intervention to forestall further deterioration. (mental status change, acute pain, acute urinary elimination problem, untreated medical problems, abnormal lab test results
Third-level priority problems
those that are important to the patient's health but can be addressed after more urgent health problems are addressed. (Knowledge deficit, altered family processes, and low self esteem)
Evidence-Based assessment
an approach to clinical evaluation in which research guides the evaluation of psychopathology, the selection of appropriate psychological tests and neuropsychological methods, and the use of critical thinking in making a diagnosis
evidence-based practice
the integration of research evidence, clinical expertise, clinical knowledge (physical assessment), and patient values and preferences
Complete (Total Health) Database
Includes complete health history and full physical examination
Describes current and past health state and forms baseline to measure all future changes
Yields first diagnoses
Focused or Problem-Centered Database
For limited or short term problem. Collect "mini" database, smaller in scope, concerns mainly one problem, one cue complex, or one body system
Follow-up database
evaluates the status of any identified problem at regular intervals to follow up on short term or chronic health problems
Emergency database
rapid collection of the database, often compiled concurrently with lifesaving measures
holistic health
the view that the mind, body, and spirit are interdependent and function as a whole within the environment
health promotion and disease prevention
Involve changing people's unhealthy behaviors through a set of positive acts. The focus is on teaching and helping the consumer choose a healthier lifestyle
Screening History
For dietary intake, physical activity, tobacco/alcohol/drug use, and sexual practices
Physical Examination
for height and weight, BP, and screening for cervical cancer and HIV
Counseling
for physical activity and risk prevention
Depression
screening
Healthy Diet
counseling, including lipid disorder screening and obesity screening