Physical Assessment

Physical Assessment - Physical Assessment Nursing Health...

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Physical Assessment h Nursing Health History is used to identify patterns of health and illness, risk factors for physical and behavioral health problems, deviation from normal, and to help find solutions Guidelines for Conducting Heath Assessment h Establish rapport i Encourage honest communication i Make eye contact i Listen carefully i Be aware of your own non verbal communication i Avoid technical terms i Consider educational and cultural background and any disabilities that the patient may have Components of the Health History h Biographical data identifies the client and may include: o Name, age, sex, race, marital status, social security number, education, occupation, religion, closest relative, physician, and medical record number i Chief Complaint a short statement recorded in the patient’s own words and in quotation marks (“I have not been able to breath for about 2 weeks) i Present Health Concern/Illness the single most important factor that the health team needs to diagnose or determine the client’s needs. The physical examination only validates the information obtained. Diagnostic test often support, rather than establish diagnosis. Gather relevant and essential data about the onset and duration of symptoms. Record information about the location, intensity, and quality of symptoms. Find out what actions precipitate the symptoms, makes them worse, or provides relief i Past History assess whether the client has ever been hospitalized, or has had surgery, description of allergies (if present, not specific reaction and treatment), identify habits and lifestyles, alcohol, tobacco, caffeine, OTC drugs or routinely taken meds, assess patterns of sleep, exercise and nutrition, check general health and immunization status, last physical exam CXR, EKG, eye exam, dental checkup, pap smear and mammogram, testicular and digital rectal exams, previous illnesses are discussed i Family History the age, health status, or the age and cause of death of relative are obtained to identify genetic, communicable, or environmental diseases. First order r elatives and second order relatives, diseases such as hypertension, heart disease, diabetes, epilepsy, mental illness, TB, kidney disease, arthritis, allergies, asthma, alcoholism and obesity. A genogram or family tree is an easy way to record such data
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Environmental History home environment, support systems, functioning of utilities, layout of rooms, presence of barriers or risks to client safety, exposure to pollutants, high crime areas, available resources i Psychosocial History reveals support system, how client deals with stress, recent losses i Spiritual Environment life experiences and events are shaped by one’s spirituality. The spiritual dimension if often difficult to assess quickly.
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This note was uploaded on 05/04/2008 for the course NURS 120 taught by Professor Rominowski during the Spring '08 term at Lady of the Lake.

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Physical Assessment - Physical Assessment Nursing Health...

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