(ch. 1-4, 6) (David Hudson) Latest Updated 2024
primary source - ANSWER-patient
secondary source - ANSWER-another individual (parent, caregiver, spouse, etc.)
physical examination - ANSWER-objective signs
*inspection
*palpation
*percussion
*auscultation
*vital signs
*height and weight
health assessment - ANSWER-systematic method of collecting and analyzing data for the purpose of
planning care for the patient
components of health assessment - ANSWER-*health history
*physical examination
*review 'other data' - labs, tests, etc.
*documentation of findings
health history - ANSWER-*subjective data during the interview
*current states of health, medication regimen
, *previous illnesses
*family history
*symptoms
documentation - ANSWER-so that the information is available for other healthcare professionals
*improves plan of care
*prevents repetition
*legal
* serves as a baseline
three types of health assessment - ANSWER-1) context of care
2) patient need
3) nurse expertise
context of care - ANSWER-1) comprehensive
2) episodic
3) focused
comprehensive assessment - ANSWER-involves a detailed history and physical assessment performed at
the onset of care
episodic - ANSWER-has in past and now have it again
EX: a patient being treated for pneumonia might be asked to return for follow-up
EX: patient with ongoing condition (diabetes) is asked to make regular visits to the clinic