1_Health Assessment

1_Health Assessment

1. 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

2. 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. 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. 4. Documentation

   • Accurate- Consise- Objective
   • Avoid WNL- Record by system- Chart Pertinent negitives
   • Follow Institution Guidelines