FAU Health Assessment Exam 1 Study Guide Top Graded 2024

Subjective Data - What the patient tells me "Symptoms" -Chief Complaint (Exact words) -History of Present Illness (Reason for visit) -Past Health History -Review of Systems -Family History (Genogram) Objective Data - What I can See and Measure -Physical Exam -Signs -General Survey (would not include cough or bp screening results at health fair) Physical Appearance Gate Speech and hygiene Nursing Assessment - Inspection Palpation Percussion Auscultation General Survey - Objective -Observe pt. general state of health, build and sexual development -Note posture, motor activity, and gait -Dress and grooming and personal hygiene -Body odors -Watch facial expressions -Note state of awareness or level of consciousness -Measure height and weight Unexplained Weight Loss - Red flag for underlying systemic disease PTSD Symptoms - -Behavioral: agitation, irritability, hostility, hypervigilance, self-destructive behavior, social isolation -Psychological: flashback, fear, severe anxiety, mistrust -Mood: loss of interest or pleasure in activities, guilt, or loneliness -Sleep: Insomnia or nightmares 7 Attributes of a Chief Complaint/Symptom - O-NSET L-OCATION D-URATION C-HARACTERISTICS A-SSOCIATED MANIFESTATIONS R-ELIEVING FACTORS T-REATMENT 7 Components of The Comprehensive Health History - 1. Identifying Data and Source of the History 2. Chief Complaint 3. History of Present Illness 4. Past History 5. Family History 6. Review of Systems 7. Health Patterns Chief Complaint - CC Subjective Symptom Why the patient has come in their exact words "Quote them" One or more complaints causing the patient to seek care History of Present Illness - HPI OLDCART Past History/Past Medical History - PH Allergies Medications Childhood illnesses Adult Illnesses Health Maintenance-Immunizations, screenings, safety measures (seat belts), drugs Alcohol use CAGE Personal and Social History - Part of Past History -Smoking Habits -Church Habits -Married and Children -Seat Belt Family History - Outline of diagram on a genogram Age and health Age and Death/cause or immediate relatives Review of Systems - Subjective Goes from Head to Toe Prepare patient for the next question or system Most pertain to symptoms Review of Systems List (16) - 1. General-weight, weakness, fatigue 2. Skin-rashes, lumps 3. HEENT (Head, Eyes, Ears , Nose, Throat) 4. Neck-Lymph nodes, stiffness 5.Breasts-lumps, nipples discharge 6.Respiratory-Cough,asthma 7. Cardiovascular-Heart, chest pain 8. Gastrointestinal- 9. Peripheral Vascular-Swelling, cramps, varicose veins 10. Urinary- 11. Reproductive 12. Musculoskeletal 13. Psychiatric 14. Neurologic 15. Hematologic 16. Endocrine Health Patterns - Personal and Social History Values Exercise/Activity Sleep Nutrition Relationships Coping/ Stress