Health Assessment Chapter 4

Purpose is to collect subjective data. By combining subjective data with objective data from the physical examination and laboratory studies, you create a database to make a judgment or diagnosis about the individual's health status

1. Biographic data 2. Reason for seeking care 3. Present health or history of present illness 4. Past history 5. Medication reconciliation 6. Family history 7. Review of systems 8. Functional assessment or activities of daily living (ADLs)

name, address, phone number, age, birthdate, gender, marital status, race, ethic origin, occupation, primary language

Record who furnishes the information, judge how reliable the informant seems and how willing, note any special circumstances

Brief, spontaneous statement in the person's own words that describes the reason for the visit

subjective evidence of a disease, such as pain or a headache

objective abnormality that you as the examiner could detect on physical examination or through diagnostic testing

Location Character or quality Quantity or severity Timing Setting Aggravating or relieving factors Associated factors Patient's perception

location of the pain

This calls for specific descriptive terms such as burning, sharp, dull, aching, gnawing, throbbing, shooting, viselike when describing pain. You also need to ask about the character of other symptoms.

Attempt to quantify the sign or symptom, such as "profuse menstrual flow soaking five pads per hour." Quantify the symptom of pain using the scale shown on the right. With pain, avoid adjectives, and ask how it affects daily activities.

when did the symptom first appear? give the specific date and time or state specifically how long ago the symptom started prior to arrival

Where was the person or what was the person doing when the symptom started? What brings it on?

What makes the pain worse? Is it aggravated by weather, activity, food, medication, standing, fatigue, time of day, or season? What relieves it (e.g., rest, medication, or ice pack)? What is the effect of any treatment?

Is this primary symptom associated with any others

Find out the meaning of the symptom by asking how it affects daily activities.

1. Childhood Illnesses 2. Accidents or Injuries 3. Serious or Chronic Illnesses 4. Hospitalizations 5. Operations 6. Obstetric History 7. Immunizations 8. Last Examination Date 9. Allergies 10. Current Medications

a comparison of a list of current medications with a previous list, which is done at every hospitalization and every clinic visit.

description of individual body systems in order to discover any symptoms not directly related to the main problem. General overall health state, skin, hair, nails, head, eyes, ears, nose, sinuses, mouth, throat, neck, breast, axilla, respiratory system, cardiovascular system, peripheral vascular, gastrointestinal, urinary system, male genital system, female genital system, sexual health, musculoskeletal system, neurologic system, hematologic system, endocrine system

a person's self-care ability in the areas of general physical health; ADLs such as bathing, dressing, toileting, eating, walking; instrumental ADLs or those needed for independent living such as housekeeping, shopping, cooking, doing laundry, using the telephone, managing finances; nutrition; social relationships and resources; self-concept and coping; and home environment. Self-esteem, self concept, activity, exercise, sleep, rest, nutrition, elimination, interpersonal relationships/resources, spiritual resources, coping and stress management, personal habits, alcohol, illicit or street drugs, environment/hazards,

How do you define health? How do you view your situation now? What are your concerns/goals? What do you think will happen in the future? What do you expect from your health care providers?

Health history adapted to include information specific for age and developmental stage of child Biographic data Source of history Person providing information and relation to child Your impression of reliability of information Any special circumstances (e.g., use of an interpreter) Reason for seeking care History of present Illness Severity of pain: note effect on usual behavior (e.g., does it stop child from playing?) Associated factors, such as relation to activity, eating, and body position Parent's intuitive sense of problem often accurate; even if proven otherwise, this gives an idea of parent's area of concern Parent's coping ability and reaction of other family members to child's symptoms or illness

do not treat like a child, be honest and respectful, ensure confidentiality, parent may or may not be present HEEADSSS

Home Education and employment Eating Activities Drugs Sexuality Suicide and depression Safety