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1.Comprehensive assessment: all the elements of the health history |\ |\ |\ |\ |\ |\ |\ |\ |\
and the complete physical examination
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2.Focused assessment: Specific area of complaint/ presenting issue
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3.Subjective data: information perceived only by the affected person
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4.Objective data: information that is seen, heard, felt, or smelled by an
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observer; signs |\
5.Primary phase: Identify and address potentially life threatening
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conditions; A-G |\
6.Secondary phase: |\ |\
History Head to toe
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- neurological
- cardiac
- respiratory
- gastrointestinal
- renal
- skin
7.ABCDEFG: A - airway |\ |\ |\
B - breathing
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C - circulation
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D - disability/ neurological
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E - exposure
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F - fluids
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1 |\/ |\47
,G - glucose
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8.IPPA: Inspect: lacerations, abrasions, bruising, oedema,
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ascites Palpate: asymmetry, tenderness
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Percuss: resonant, hyper resonant, dull |\ |\ |\ |\
Auscultate: lung sounds, adventurous sounds, heart sounds, bowel sound
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9.PQRST: P - provoking factors |\ |\ |\ |\
Q - quality
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R - region/ radiation
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S - severity
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T - time
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10.FLACC: Used for paediatric patients 2 months - 7 |\ |\ |\ |\ |\ |\ |\ |\ |\
years F - face |\ |\ |\
L - legs
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A - activity
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|\ C - cry
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C - consolability
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11.Head to toe assessment: 1. General survey, vital signs and pain
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2.Mental status and neurological techniques |\ |\ |\ |\
2 |\/ |\47
,3.Skin, hair and nails
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4.Head, neck and regional lymphatics
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5. Eyes
6.Ears, nose, mouth and throat
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7.Breasts and regional nodes |\ |\ |\
8.Thorax and lungs |\ |\
9.Heart and blood vessels
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10.Abdomen and nutrition |\ |\
11.Musculoskeletal system |\
12.Female and male genitalia |\ |\ |\
13.Anus, rectum and prostate
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12.Gordon's functional health patterns: 1. Health perception - health
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manage- ment pattern |\ |\
2.Nutritional - metabolic pattern |\ |\ |\
3.Elimination pattern |\
4.Activity - exercise pattern |\ |\ |\
5.Sleep - rest pattern
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6.Cognitive - perceptual pattern |\ |\ |\
7.Self perception - self concept pattern
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8.Role - relationship pattern
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9.Sexuality - reproductive pattern |\ |\ |\
10.Coping - stress tolerance pattern |\ |\ |\ |\
11.Value - belief pattern |\ |\ |\
13.Standard 1: Thinks critically and analyses nursing practice
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3 |\/ |\47
, 14.Standard 2: Engages in therapeutic and professional relationships
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15.Standard 3: Maintains the capability for practice
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16.Standard 4: Comprehensively conducts assessments
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17.Standard 5: Develops a plan for nursing practice
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18.Standard 6: Provides safe, appropriate and responsive quality nursing
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practice
19.Standard 7: Evaluates outcomes to inform nursing practice
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20.Development stages: Stage 1 infancy (birth to 1 |\ |\ |\ |\ |\ |\ |\
|\ yr) Stage 2 toddler (1 to 3yrs)
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Stage 3 preschooler (3 to 6yrs)
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Stage 4 school-age child (6 to
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12yrs) Stage 5 adolescence (12
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to 18yrs) Stage 6 young adult
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(18 to 30yrs) |\ |\
Stage 7 early middle adulthood (30 to
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50yrs) Stage 8 late middle adulthood (50
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to 70yrs) Stage 9 late adulthood (70yrs to
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|\ death)
4 |\/ |\47