Physical assessment

• Health is defined as a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.
• Health is a process and a state of being and becoming whole and integrated in a way that reflects person and environment mutuality.
• Health is the state of a person as characterized by soundness or wholeness of developed human structures and mental and bodily functioning that requires therapeutic self-care.
• Health is a culturally defined, valued, and practiced state of well-being reflective of the ability to perform role activities.
• Health is a state of well-being and use of every power the person possesses to the fullest extent.
• The Ecologic Model (Leavell and Clark 1965) examines the interaction of Agent Host and Environment.
• In the Ecologic Model, health is present when these three variables are in harmony.
• Collaborative diagnosis can be challenging due to the need to coordinate the efforts of multiple healthcare professionals.
• A collaborative diagnosis is a process where multiple healthcare professionals work together to diagnose a patient.
• The success of a collaborative diagnosis depends on the quality of the information gathered and the ability of the healthcare professionals to work together.
• The goal of a collaborative diagnosis is to provide the most accurate diagnosis possible.
• The process of a collaborative diagnosis involves gathering information from various sources, including medical records, physical examinations, and consultations with specialists.
• When harmony is disrupted, health is not maintained at its highest level and illness and disease occur.
• The Clinical Model defines health as the absence of disease or injury.
• The Health Promotion Model (Pender, Murdaugh and Parsons 2011) defines health as the actualization of inherent and acquired human potential through goal-directed behavior, competent self care, and satisfying relationships with others, while adjustments are made to maintain structural integrity and harmony with relevant environments.
• The purpose of health assessment is to establish a database of client’s normal abilities, risk factors that can contribute to dysfunction and any current alteration in function.
• Health assessment aims to obtain a clear picture of client’s health status and health related problems.
• Health assessment helps identify cause and extent of disease.
• Health assessment facilitates communication and coordination.
• Health assessment helps arrive at a definite nursing diagnosis.
• The final step of the nursing process involves evaluating the care plan based on the initial goals and desired outcomes.
• Health Assessment is a systematic method of collecting data about a patient for the purpose of determining the patient’s current and ongoing health status, predicting risks to health, and identifying health-promoting activities.
• Goals/Expected Outcomes in Nursing Process are Measurable and Goal-oriented.
• Documentation of data creates the patient’s medical record, is a legal document used to plan care, communicate information between and among health care providers, is used for reimbursement of services, and is data for research.
• In the third step of the nursing process, the nurse develops a care plan drawing on information from the nursing diagnosis.
• The nursing diagnosis instructs the specific nursing care that the patient shall receive.
• Maslow’s Hierarchy of Needs is a concept in Nursing Process.
• If the results of the evaluation do not align with the initial goals and desired outcomes, the care plan can be adjusted based on the patient’s needs.
• NANDA List includes Problem-Focused Nursing Diagnosis, Risk Nursing Diagnosis, Health Promotion Nursing Diagnosis, Syndrome Nursing Diagnosis, and Possible Nursing Diagnosis.
• Nursing Process is a systematic, rationale, dynamic and cyclical process used by the nurse for assessing, planning, implementing and evaluating care for the patient.
• The data collected in Health Assessment include physical, social, cultural, environmental, and emotional factors that impact the overall well-being of the patient.
• Nursing Process involves Collection of Subjective and Objective data, health History, psychological and socio-economic assessments.
• Health assessment recommends appropriate interventions.
• Documentation Guidelines must be accurate, confidential, appropriate, complete, and detailed.
• Health assessment identifies need for health teaching.
• Comprehensive Health Assessment is a type of health assessment.
• Problem-based or focused health assessment is a type of health assessment.
• Episodic assessment is a type of health assessment.
• Screening assessment is a type of health assessment.
• Components of health assessment include Health History, Physical Assessment, and Communication.