RATED A+
What does assessment mean?
collec on of data about an individual's health state
Subjec ve data
what the subject says about themselves during assessment
Objec ve Data
what you sense during assessment process
see, hear, smell, feel
Database
en re pa ent's file, including lab studies
Diagnos c reasoning:
analyzing all data and drawing conclusions to iden fy diagnosis
First-Level Priority
emergent, life threatening
ABC's
airway
breathing
circula on
second-level priority
needs a*en on before it becomes a first level
examples of second level priori es
mental status change
acute pain
infec on risk
, abnormal labs
safety risks
third-level priori es
important, but can be helped a-er first and second levels are cleared
Third-level priority problems
knowledge deficit, mobility issues, family coping
complete database
complete health history and full physical examina on. done in primary care se0ngs
includes minor things like wisdom teeth removal at early age
focused (problem-centered) database
collect a targeted history and physical examina on around area of concern. completed in all
se0ngs
follow-up database
used to check status of known issue to verify if change has occured
completed in all se0ngs
emergency database
urgent, rapid collec on of info in conjunc on with life-saving measures. complete database can
follow once pa ent is stable
culture
includes a0tudes, values, beliefs, norms, and roles
culture is
learned from birth
shared by all group members
adapted to environmental factors