NSE 13A/B Chapter Notes - Chapter 1: Physical Examination, Risk Assessment, Health Promotion
Document Summary
Assessment: point of entry in an ongoing process. Collection of data about an individual"s health state. Subjective data: what the person says about him/herself during history taking. Objective data: what the hcp observes by inspecting, percussing, palpating, and auscultating during the physical examination. Nursing process/standards of practice in nursing: assessment. Compare clinical findings with normal and abnormal variation and developmental events. Document implementation and any modification: evaluation. Use ongoing assessment to revise diagnoses, outcomes, plan. Setting priorities: first-level priorities: emergencies, life-threatening immediate, second-level: necessitating prompt intervention to forestall further deterioration, third-level: important to pt"s health but can be addressed after more urgent health problems. Collaborative problems: the approach to treatment involves multiple disciplines. Evidence-based practice/evidence-informed practice: a systematic approach to practice that emphasizes the use of best evidence in combination with the clinician"s experience, as well as the patient preferences and values, to make decisions about care and treatment.
