EXAMINATION AND HEALTH
ASSESSMENT EXAM REVIEWED
STUDYGUIDE
subjective data
what the person says about himself or herself during
history taking
objective date
what you as the health professional observe by inspective,
percussing, palpating, and auscultating during the physical
examination
database
subjective data, objective data, patient's record, and
laboratory studies
diagnostic reasoning
the process of analyzing health data and drawing
conclusions to identify diagnoses
nursing process
the standards of practice in nursing :
- assessment
- diagnosis
- outcome identification
- planning
- implementation
- evaluation
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
assessment
the collection of data about an individual's health state
biomedical model
the Western European/North American tradition that views
health as the absence of disease
complete database
a complete health history and full physical examination
critical thinking
simultaneously problem solving while self-improving one's
own thinking ability
diagnostic reasoning
a method of collecting and analyzing clinical information
with the following components: (1) attending to initially
available cues, (2) formulating diagnostic hypotheses, (3)
gathering data relative to the tentative hypotheses, (4)
evaluating each hypothesis with the new data collected,
and (5) arriving at a final diagnosis
emergency database
rapid collection of the database, often compiled
concurrently with lifesaving measures
environment