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WEB Intro To Health Assessment - Techniques-General Survey
WEB Intro To Health Assessment - Techniques-General Survey
HEALTH ASSESSMENT
•TECHNIQUES OF PHYSICAL ASSESSMENT
•GENERAL SURVEY
Health Assessment
Is
holistic data collection AND
analysis
Interval
Problemfocused or chief
complaint
History Taking
Well developed interview skills and
careful documentation
Environment conducive to privacy
and comfort
Is the client a good historian?
Reasons for seeking health care
Interview- intro, working,
termination phases
Complete Health History
Biographical Review of systems
Reason for seeking Psychological
health care Functional
Present Assessment
health/Illness Perception of
Past health health
Family health
Present Health/Illness
Reason for seeking care
Onset, duration, precipitating
factors.
Frequency, duration…
Associated symptoms i.e. N/V
Alleviating/ aggravating factors
Relevant family, occupational or
recreational history.
Past Health History
Past general health
Childhood illnesses
Accidents/ injuries
Hospitalizations/surgeries
Acute and chronic illnesses
Immunizations
Allergies, medications, transfusions
Obstetric History
Current Health
Habits
Meds (including
OTC/Herbal/Vitamins)
Exercise
Sleep
Family History
Important to know to determine
risks
Status of family members
Parents, siblings, grandparents
Status of spouse/significant
other and Children
Construct Genogram
Review of Systems: ROS
Review past and present
health status of each body
system.
Review health maintenance.
A Head-to- Toe approach
May elicit new information
Psychological Function
Cognitive – memory,
comprehension
Response to illness and health
Psych history, meds, anxiety?
Cultural considerations
Functional Assessment
ADLs
Sleep/rest
Nutrition/problems with diet, weight
Alcohol /Substance abuse
Smoking history (in pack years)
Coping difficulties
Domestic/ child abuse
Perception of Health
How one defines health
Views on one’s health status
What are one’s expectations
pertaining to health and
health care
Physical Examination (PE)
Gait Facial
expression
Rangeof
Mood
Motion (PROM
Speech
or AROM)
Dress/Hygiene
General Survey
Includes Height & Weight
Vital signs: Temperature, Pulse,
Respiration & Blood Pressure
Recognize transcultural
considerations
Note S/S (signs/symptoms) of
distress/pain
Assessing
Distress/Pain
Assessment includes:
S- Severity
L- Location
I- Influencing factors
D- Duration
A- Associated Symptoms
Assessing Distress/Pain