Health Assessment

2. Physical Assessment
1. A. General Survey
  1. Obvious Abnormalities, signs of distress, Substance abuse,
  2. Age, race, gender, affect, speech, dress
  3. LOC
    1. Alert and Oriented x 3 (AO3)
      1. Who (Can you tell me your name?)
      2. Where (Can you tell me where you are?
      3. What? Can you tell me why you're here?
      4. When (Can you tell me what time it is?)
2. B. Measurements
  1. Vital Signs
    1. TPR
      1. Temperature 96-100
      2. Pulse 60-100
      3. Respirations 12-20
    2. Blood Pressure 120/80
    3. 02 Stauration 98%
    4. Level of Comfort/Pain 1-10
  2. Height
  3. Weight
3. C. Head To Toe
  1. General Survey
    1. Distress, color, symmetry, Appearance, Equipment
  2. Neurological
    1. LOC Awake Alert, And Oriented
      1. Awake, Aware of your presense,
    2. Orientation (AO x4)
    3. Ability to communicate
    4. Face Symmetry
    5. Pupils (PERRLA)
      1. Pupils are equal round, reactive to light, and accomodate
    6. Strength
    7. Sensation
    8. Gait
  3. Respiratory
    1. Rate, Rythm , Quality
    2. Breathe sounds -Symmetry, quality
    3. Chest Excursion and accessory muscle use
    4. Pulse Ox
  4. Cardiovascular
    1. Apical Rate, Rhythm, S1S2, Quality, Abnormal Sounds
    2. Pulse- head to toe
      1. Carotid
      2. Brachial- radial
      3. Femoral, popliteal, dorsalis pedis, posterior tibial
    3. Color (Lips, Periphery)
    4. Temperature
    5. Capillary Refill- Within 3 seconds
    6. Neck Vein distension
    7. presence of Edema
  5. Gastrointestinal
    1. Inspection- contour scars, dressings)
    2. Auscultation (Bowel Sounds) 5 minutes in every quadrant- until you hear a sound. (Present, Hyperactive, hypoactive, absent
    3. Palpation (Soft, Firm, Distended)
  6. Genitourinary
    1. Genitalia- hemorrhoids, drainage, inspection
    2. Urine Output (Foley)
  7. Musculoskeletal
    1. Range of motion (ROM)
    2. Joints
    3. Strength/ Symmetry
  8. Integumentary
    1. Skin (integrity, Moisture, turgor, color, teperature
    2. Hair
    3. Nails
1. Health Hx- Subjective
1. A. Prep
  1. Physical Evironment
    1. Ensure Patient Safety
      1. No Hazards
    2. Patient Comfort
      1. Temperature
      2. Blankets
    3. Ensure Privacy
      1. Curtain
  2. Psychological Prep
    1. Comfort Patient if Nervous
    2. Explain Everything
  3. Review Diagnostic Tests
2. B. Orientation
  1. Introduce Self, who you are, Why you are there, Get PT name,
3. C. Working
  1. Biographical Data
    1. Name, Date of Birth, age gender, race, ethnicity, martial status, religion
    2. Adress and Phone number, emergency contact , referral source, insurance, advance directive
  2. Current Health Status
    1. Why are you being seen today? Chief Complaint OLDCARTS, SAMPLE< OPQRST
      1. Symptoms, Allergies, Medications, Pertinent Past History, Last Oral Intake, Events leading up to visit
      2. Onset, Provocation, Quality, Radiation, Severity, Time
    2. Does the problem effect activity level? Major Concerns?
    3. Clients Perception of Health
  3. Past Health Hx
    1. Examples: Hospitalizations, Allergies, Serious injuries, Surgeries, Medications, Travel, Childhood illnesses, Reproductive Patterns- Children Menopause ect.
  4. Review of Systems
    1. Consider developmental age, education level- Put symptoms together organize by system.
  5. Family Hx
    1. Genetic disorders
    2. Support system
  6. Psycho-social Hx
    1. Activity- Sleep- Nutrition
    2. Recreation- Hobbies- Personal Habits
    3. Depression, Anxiety, Suicidal Ideation
4. D. Termination
  1. Anything else you want to tell me?
  2. What do I need to know to better take care of you?
  3. I have two more questions.
3. Data Validation
1. Compare Subjective and Objective Data
2. Ask Client to Verify Data
3. Use other sources to validate data- family, HCP, Records, tests, labs
4. Documentation
1. Accurate- Consise- Objective
2. Avoid WNL- Record by system- Chart Pertinent negitives
3. Follow Institution Guidelines

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Health Assessment

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	Created by Gwen Paparone about 8 years ago