Zusammenfassung der Ressource
Health Assessment
- 2. Physical Assessment
- A. General Survey
- Obvious Abnormalities,
signs of distress,
Substance abuse,
- Age, race,
gender, affect,
speech, dress
- LOC
- Alert and Oriented x 3 (AO3)
- Who (Can you tell me your name?)
- Where (Can you tell me where you are?
- What? Can you tell me why you're here?
- When (Can you tell me what time it is?)
- B. Measurements
- Vital Signs
- TPR
- Temperature 96-100
- Pulse 60-100
- Respirations 12-20
- Blood Pressure 120/80
- 02 Stauration 98%
- Level of Comfort/Pain 1-10
- Height
- Weight
- C. Head To Toe
- General Survey
- Distress, color,
symmetry, Appearance,
Equipment
- Neurological
- LOC Awake Alert, And Oriented
- Awake, Aware of your presense,
- Orientation (AO x4)
- Ability to communicate
- Face Symmetry
- Pupils (PERRLA)
- Pupils are equal round,
reactive to light, and
accomodate
- Strength
- Sensation
- Gait
- Respiratory
- Rate, Rythm , Quality
- Breathe sounds -Symmetry, quality
- Chest Excursion and accessory muscle use
- Pulse Ox
- Cardiovascular
- Apical Rate, Rhythm,
S1S2, Quality, Abnormal
Sounds
- Pulse- head to toe
- Carotid
- Brachial- radial
- Femoral, popliteal,
dorsalis pedis,
posterior tibial
- Color (Lips, Periphery)
- Temperature
- Capillary Refill- Within 3 seconds
- Neck Vein distension
- presence of Edema
- Gastrointestinal
- Inspection-
contour scars,
dressings)
- Auscultation (Bowel
Sounds) 5 minutes in every
quadrant- until you hear a
sound. (Present,
Hyperactive, hypoactive,
absent
- Palpation (Soft, Firm, Distended)
- Genitourinary
- Genitalia-
hemorrhoids,
drainage, inspection
- Urine Output (Foley)
- Musculoskeletal
- Range of motion (ROM)
- Joints
- Strength/ Symmetry
- Integumentary
- Skin (integrity,
Moisture, turgor,
color, teperature
- Hair
- Nails
- 1. Health Hx- Subjective
- A. Prep
- Physical Evironment
- Ensure Patient Safety
- No Hazards
- Patient Comfort
- Temperature
- Blankets
- Ensure Privacy
- Curtain
- Psychological Prep
- Comfort Patient if Nervous
- Explain Everything
- Review Diagnostic Tests
- B. Orientation
- Introduce Self, who you are, Why you are there, Get PT name,
- C. Working
- Biographical Data
- Name, Date of Birth, age gender, race, ethnicity, martial status, religion
- Adress and Phone number, emergency contact , referral source, insurance, advance directive
- Current Health Status
- Why are you being seen today? Chief Complaint OLDCARTS, SAMPLE< OPQRST
- Symptoms,
Allergies,
Medications,
Pertinent Past
History, Last Oral
Intake, Events
leading up to visit
- Onset,
Provocation,
Quality,
Radiation,
Severity,
Time
- Does the problem effect activity level? Major Concerns?
- Clients Perception of Health
- Past Health Hx
- Examples: Hospitalizations, Allergies,
Serious injuries, Surgeries, Medications,
Travel, Childhood illnesses,
Reproductive Patterns- Children
Menopause ect.
- Review of Systems
- Consider developmental age, education
level- Put symptoms together organize by system.
- Family Hx
- Genetic
disorders
- Support system
- Psycho-social Hx
- Activity- Sleep-
Nutrition
- Recreation- Hobbies- Personal
Habits
- Depression, Anxiety, Suicidal
Ideation
- D. Termination
- Anything else you want to tell me?
- What do I need to know to better take care of you?
- I have two more questions.
- 3. Data Validation
- Compare Subjective and Objective Data
- Ask Client to Verify Data
- Use other sources to
validate data- family,
HCP, Records, tests, labs
- 4. Documentation
- Accurate- Consise- Objective
- Avoid WNL- Record by system-
Chart Pertinent negitives
- Follow Institution
Guidelines