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6995931
1_Health Assessment
Description
Mind Map on 1_Health Assessment, created by Marvin Baca on 15/11/2016.
No tags specified
health assessment
health
patient assessment
nursing assessment
nursing process
fundamentals of nursing
hx
physical assessment
Mind Map by
Marvin Baca
, updated more than 1 year ago
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Created by
Gwen Paparone
almost 8 years ago
Copied by
Marvin Baca
almost 8 years ago
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Resource summary
1_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
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