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    Review of The Nursing Process

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    markkkkkkkheeess
    The document outlines guidelines for conducting a health history and physical examination in nursing. It discusses conducting an interview, collecting data on a patient's personal profile including their chief complaint and medical history, assessing functional status, reviewing systems, and documenting findings from a physical exam. The goal is to gather comprehensive information on a patient's health to inform an appropriate nursing diagnosis.

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    Attribution Non-Commercial (BY-NC)
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    Review of The Nursing Process

    Uploaded by

    markkkkkkkheeess
    903 views2 pages
    The document outlines guidelines for conducting a health history and physical examination in nursing. It discusses conducting an interview, collecting data on a patient's personal profile including their chief complaint and medical history, assessing functional status, reviewing systems, and documenting findings from a physical exam. The goal is to gather comprehensive information on a patient's health to inform an appropriate nursing diagnosis.

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    Review of the Nursing Process

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    The document outlines guidelines for conducting a health history and physical examination in nursing. It discusses conducting an interview, collecting data on a patient's personal profile including their chief complaint and medical history, assessing functional status, reviewing systems, and documenting findings from a physical exam. The goal is to gather comprehensive information on a patient's health to inform an appropriate nursing diagnosis.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    903 views2 pages

    Review of The Nursing Process

    Uploaded by

    markkkkkkkheeess
    The document outlines guidelines for conducting a health history and physical examination in nursing. It discusses conducting an interview, collecting data on a patient's personal profile including their chief complaint and medical history, assessing functional status, reviewing systems, and documenting findings from a physical exam. The goal is to gather comprehensive information on a patient's health to inform an appropriate nursing diagnosis.

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    I.

    Review of the Nursing Process


    II. Health History Guidelines
    A. Interview
    1. Purpose
    2. Structure
    3. Guidelines of an effective interview
    III. Health History
    A. Personal profile
    1. Biographical Data
    2. Chief complaint of present illness
    a. Usual health status
    b. Chronological story
    c. Impact on functioning
    d. Medications
    3. Past health history
    4. Current medications
    5. Personal habits & patterns of living (ADL)
    6. Psychosocial History
    a. Mental Status Assessment
    Children and Adolescent
    Adults
    B. Functional Assessment
    1. Adults
    2. Physical activities of daily living (PADC)
    3. Instrumental activities of daily living (IADL)
    C. Functional Assessment Tests
    1. Newborns – Apgar scoring system
    2. Infants & children – MMDST
    3. Adults
    a. Katz Index of Independence in ADL
    b. Barthel index
    D. Review of Systems (Symptoms)
    E. Assessment in pregnancy (e.g. LMP, EDC)
    F. Pediatric Additions to Health History (e.g. head circumference, weight,
    height, immunization)
    G. Geriatric Additions to the Health History (e.g. immunization, current
    prescription medications, over the counter medications, ADL, social
    support, etc.)
    IV. Physical Examination
    A. Preparation guidelines
    B. PE guidelines
    C. Techniques in Physical assessment
    1. Inspection
    2. Auscultation
    3. Percussion
    4. Palpation
    D. Continuing Assessment
    1. Pain
    2. Fever
    E. Pediatric Adaptation
    1. General guidelines
    2. Specific age groups
    F. Geriatric adaptations
    1. General guidelines
    2. Modifications
    G. Cultural considerations
    1. Sequence of PE (adult/pedia/geriatric adaptations)
    a. Overview
    b. Integument
    c. Head
    d. Neck
    e. Back
    f. Anterior Trunk
    g. Abdomen
    h. Musculoskeletal system
    i. Neurologic system
    j. Genitourinary system
    H. Clinical alert
    I. Documentation of findings
    J. Patient & Family Education & Home Health Teaching
    V. Diagnostic Tests (routine laboratory exams)
    VI. Appropriate Nursing Diagnosis

    Chief Complaint

    Present Problem

    a. Usual health status


    b. Chronological story
    c. Impact on functioning
    d. Medications

    Past Medical History

    Family History

    Personal & Social History

    Review of Systems or Functional Patterns

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