Intro to Health Assessment
What is involved in a health assessment?
Involves the collection, clinical judgment and eval of data in order to plan and deliver pt centered care. Account for pt preference, goals and needs
What do you do for an initial survey?
Perform a quick overall assessment of the client and note any body system issues that will require a more focused assessment.
Establish trust
Build rapport
What are the key elements of the health interview?
P- PMH, previous illnesses and state of health
L- Last oral intake
E- Events leading up to this illness/injury
A-Allergies/reactions
S- Symptoms or chief complaint
E- current medications/OTC/herbal
What is a comprehensive assessment?
Full head to toe exam
What are two categories of communication?
Verbal-actively listening, expressing empathy, being respectful, showing acceptance.
Nonverbal- body language communicates warmth, interest and availability, ensure therapeutic distance, sit at eye level, make eye contact
What are the key elements of a pain assessment?
P- pattern or precipitating factors
Q- quality
R- radiates
S- severity
T- time and treatment
What is a focused exam?
The assessment of either a body system or body part
What does the initial survey and assessment include?
Observe clients appearance, behavior, body structure and mobility. Height, weight, BMI, vital signs and pain
What does the health history include?
Biographic data
reason for seeking care
history of present illness
social determinants of health
Assessment, analysis, planning, implementation and evaluation
What is objective data?
Obtained through direct assessment of a client (inspection, percussion, palpation and auscultation.
What should a medical history include?
Childhood illnesses
Injuries
Past surgeries
Hospitalizations
Immunizations
Allergies
Medications
What are 4 assessment techniques?
Inspection, auscultation, palpation and percussion
What is subjective data?
Information that the client tells you in response to assessment questions.
What does a functional assessment include?
Investigates the clients lifestyle, living environment, ability to perform ADLs.