Module 1 - Intro to Adult Phyical Assessment Flashcards
Subjective Data
information provided by the affected individual
objective data
information obtained by the health care provider through physical examination, patients record’s and laboratory studies
Diagnostic reasoning
process of analyzing health data and drawing conclusions to identify diagnoses
the nursing process has what 5 phases
assessment, nursing diagnosis, planning, implementation and evaluation
First-level of priority problems
emergent, life-threatening and immediate and require urgent measures such as establishing an airway or supporting breathing
second-level of priority problems
next in urgency. They require prompt intervention to prevent deterioration; these problems may include a mental health change or acute pain
third-priority problems
important to the patient’s health but can be addressed after dealing with more urgent problems
collaborative problems
physiological complications in which the approach to treatment encompasses multiple disciplines (alcohol withdrawal, which affects the central nervous system and the cardiovascular system) Nurses have the primary responsibility to diagnose the onset of such problems and monitor changes in status
Complete (total health) Database
includes complete health history and findings from a full physical examination
Episodic (problem centered) Database
used for a limited or short-term problem. It’s smaller in scope and more targeted than the complete database
Follow-up Database
evaluates the status of any identified problem at regular intervals to follow up on short term or chronic health problems
biomedical model
western medicine views health as the absence of disease.It focuses on collecting data on biophysical signs and symptoms and on curing disease
behavioural model
extends beyond treating disease to include primary and secondary prevention with emphasis on changing behaviours and lifestyle
socioenvironmental model
encompasses the biomedical and behavioural models and incorporates sociological and environmental aspects of health
medical diagnosis
what is exactly wrong with the patient due to signs and symptoms and tests
