adpie

assessment objective

vital signs, intake and outtake of fluid, height weight -abcs -gather info

assessment subjective

current complain, history, meds -ask questions

diagnosis

clinical judgment about actual or potential problems to help prioritize and plan care -inform health care team

planning

goals and outcomes made and personalized to individuals unique needs -action plan

implementation

carrying out interventions -perform action plan -educate patient -like giving meds

evaluation

evaluate implementation to see if desired need has been met -document patient response and sign and symptoms

assessment

initial process of gathering and collecting patient data -subjective and objective info

analysis

interpreting and evaluating collected data to identify patterns, problems, and make informed decisions

functional assessment

identifying factors that predict and maintain behaviours of concern -address things done in daily life

health assessment

collection of objective and subjective data to develop a data base about a patients health status (past and present), health concerns, and usual coping mechanisms so that an individualized care plan can be created. -health history, physical examination, documentation of findings, and analysis of data.

head to toe

to evaluate a patients overall health -comprehensive check of all major body systems

5 stages

assessment, analysis, planning, implementing, evaluating

comprehensive assessment

complete health history and physical examination