Review Of The Nursing Process

I. II.

III.

IV.

Review of the Nursing Process Health History Guidelines A. Interview 1. Purpose 2. Structure 3. Guidelines of an effective interview 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.) Physical Examination A. Preparation guidelines B. PE guidelines C. Techniques in Physical assessment 1. Inspection 2. Auscultation 3. Percussion 4. Palpation

V. VI.

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 Diagnostic Tests (routine laboratory exams) Appropriate Nursing Diagnosis

Chief Complaint Present Problem a. b. c. d.

Usual health status Chronological story Impact on functioning Medications

Past Medical History Family History Personal & Social History Review of Systems or Functional Patterns