Anatomy (Structure)
Physiology (Function)
Structure
Function
Priorities
- ACTUAL (life threating
manifestations) – exhaust
this first before moving on to
potential
- POTENTIAL (risks)
- HEALTH PROMOTION
(enhancement of specific
health behaviors) -discharge
planning
- WELLNESS (when pt.
wishes to achieve a higher
level of health)
Pathophysiology
Health History
Physical Assessment
Definition:
Etiology:
Pathway:
Signs/Symptoms
Complications
Lab/Diagnostics
Medical/Surgical
Management
Demographics
(Biographical data)
Chief complaint
History of present
illness
Medical history,
Allergies
Surgical history
Medications
Previous lab works/
diagnostics
Family hx. -illness
Personal hx/ Lifestyle
Social hx. – family
relationships
Ethnic/cultural
affiliations
Education background
Economic status
Psychosocial Data –
coping mechanisms
communication
Patterns of Health –
healthcare resources
Functional assessment –
health-perception/
health- management
pattern, nutrition,
Elimination, activity/
exercise, sleep/rest
pattern, etc.
VS:
Nursing Interventions/ Rationale
PRIORITIZE: in acute care…
1.Physiological Integrity: life threatening
event
2.Safety and effective care environment
3.Health Promotion and Maintenance
4.Psychosocial Integrity
Treatments
Meds
Labs/ Diagnostics
CNS:
CV:
Resp:
GI:
GU:
M/S:
Evaluation
Documentation
Report
Timeline