Health Assesment and PE Flashcards
systematic method of collecting SUBJECTIVE and OBJECTIVE data to establish a patient’s overall level of functioning in order to make a professional clinical judgement
health assesment
to determine patient’s current and ongoing health status, predict risks to health, and identify health promoting activities
health assesment
- detect during examination, lab info and test data
-directly or indirectly observed through measurement
objective
What the patient tells you
- verified by client
- client interview
subjective
symptoms and history from Chief Complaint through Review of Systems
subjective
physical examination findings or signs
objective
clinician should have a basic knowledge of what when doing health assesments
- anaphy
- interviewing skills
- types and operations of equipment needed for a particular examination
- preparation of the setting, oneself and the patient for the PE
- Performance of : inspectionm, plapation, percussion, and auscultation
usually done when patient has no record
comprehensive adult health history
- age, gender, occupation, martial status, birthday and address
- source of history
- source of referral
- reliability
identifying data and source of the history
one or more symptoms causing the client to seek care
chief complaints
- complete, clear, and chronologic account of the problems prompting the patient to seek care
- amplifies the chief complaint: describes how each symptom developed
-includes the problem’s onset, setting and its manifestations and any treatments
present illness
includes health maintenance practices such as immunizations, screening tests, lifestyle issues and home safety
past health history
dates of onset, info about hospitalizations with dates, number and gender of sexual partners: risky sexual practices
medical
dates, indicationws and type of operation
surgical
obstetric history, menstrual history, birth control, and sexual function
obstetric
illness and time frame, diagnoses, hospitalizations and treatments
psychiatric
reviewing conditions whether present or absent in the familly
family history
documents presence or absence of common symptoms related to each of the major body systems
review of systems
sources of data
primary and secondary
client, unless confused, too young or too ill to partricipate in an interview
primary
family members, caretakers, and support individuals as well as previous medical or health records and laboratory and diagnostic data
secondary
organized, systematic process of collecting objective data about the client’s health based upon the head to toe general system
physical examination
before the PE, what to do to make a patient more comfortable
offer patient to empty his or her bladder
use of vision to distinguish normal from abnormal findings
inspection
sitting upright provides full expansion of lungs and better visualization of symmetry of upper body parts
sitting
most normally relaxed position for easy access to pulse sites
supine
for abdominal assessment because it promotes relaxation of abdominal muscles
dorsal recumbent
provides maximal exposure of genitalia and lacilitates insertion of vaginal speculum
lithotomy
flexion of hip and knee improves exposure of rectal area
sims
for assesing extension of hip, joint, skin and buttocks
prone
helps to detect murmurs
lateral recumbent
provides maimal exposure of rectal area
knee chest
involve the use of the hands to touch body parts and make sensitive assesments
palpation
in palpation how many quarters of the abdomen to assess
4 quarters
depresses the skin 1 to 2 cm
light
about 5 to 8 cm
deep
involves tapping the client’s skin to assess underlying structures and to determine vibrations and sounds
percussion
involves listening to sounds produced by the body, such as heart, lung, or bowel sounds
auscultation
unaided ears
direct
use of stethoscope
indirect
