This document outlines the process for completing a health assessment. It involves preparing equipment, environment, and the client. A health history is then taken, including biographical data, chief complaints, present/past/family medical histories, and reviews of systems. Both subjective data from the client and objective data from examinations are collected. Health histories can be comprehensive for new/nonemergent patients or focused for ongoing/emergency cases. Functional assessments are also performed.
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- Date collection and chief complaint.
- Present History
- Past History
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- Family History.
In those slides, also include the behaviour of doctor or dentist.
During interview, Dentist should be :
introduce yourself and asking some normal questions => patient feel comfortable for moving forward.
always listen carefully.
keep your appearance neat and clean => gain trust.
show courteous, respectful and confidential
always be friendly and interest in patients’ problems.
keep eye contact.
Definition
(Health, Assessment, evaluation and observation)
Health assessment steps
(Health History, Physical Examination & Documentation of Data)
Source of data
(primary or secondary)
Phases of the nursing process
(Assessment, Diagnosis, Planning, Implementation & evaluation)
Types of health assessment
(Comprehensive, Problem-based, Emergency, Episodic, Shift & Screening).
Assignment 1: Application – Comprehensive Patient Assessment
When completing practicum requirements in clinical settings, you and your Preceptor might complete several patient assessments in the course of a day or even just a few hours. This schedule does not always allow for a thorough discussion or reflection on every patient you have seen. As a future advanced practice nurse, it is important that you take the time to reflect on a comprehensive patient assessment that includes everything from patient medical history to evaluations and follow-up care. For this Assignment, you begin to plan and write a comprehensive assessment paper that focuses on one female patient from your current practicum setting.
To prepare
Please ensure no plagiarism
·
Reflect on your Practicum Experience and
select a female patient
(
you can choose, HPV, fibroids, infertility, ovarian cyst, or chronic
bacterial
vaginosis as the topic)
·
Think about the details of the patient’s background, medical history, physical exam, labs and diagnostics, diagnosis, treatment and management plan, as well as education strategies and follow-up care.
To complete
Write an 8- to 10-page comprehensive paper that addresses the following:
1. General patient information
a. Age
b. Race/ethnicity
c. Partner status
2. Current health status
a. Chief concern/complaint and history of present illness (include a complete
symptom analysis of chief complaint(s) utilizing OLDCART for a sick/problem
focused visit)
b. Last menstrual period or year of menopause
c. DES exposure (if born between 1948 and 1971)
d. Sexual activity status
e. Barrier prevention
f. Sexual preference
g. Satisfaction with sexual relations
3. Contraception method (if any)
4. Patient history
a. Past medical history
• Major medical events (including pediatric events)
• Psychological and mental health
• Surgeries and/or hospitalizations if pertinent
• Medications, including prescriptions, over-the-counter medications, home
and herbal remedies, calcium, and vitamin supplements
• Allergies, including drug, food, and environment
• Health maintenance/screenings, including results of patient’s last Pap and
mammogram as appropriate, as well as previous vaccinations (HPV,
MMR, hepatitis B, last dT, and pneumovax/influenza as appropriate)
b. Family medical history
c. Gynecologic history
• Nullipara vs. multipara
• History of sexually transmitted infections and sexually transmitted
diseases
• Menarche and menstrual patterns
• Menopause or peri-menopausal symptoms (if applicable)
d. Obstetric history
• Gravida and parity status (TPAL)
• Pregnancy history, including history of preterm or low birth weight, other
pregnancy complications, history of sexually transmitted diseases, and
any pertinent negatives
e. Personal social history (as appropriate to the current problem)
• Cultural background
• Education and economic condition
• Abuse history including assault and forced sex (past and current)
• Occupational health patterns
• Env.
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3. Preparation of the equipment :
• Be sure that’s the equipment is in
good condition working well
• Clean well arranged according to use
• All infection control measures should
be taken under consideration
4. Preparation of physical environment:
• Clean wells furnished place
• Quiet
• Proper temperature
• Proper ventilation
• Proper humidity
• Proper light – natural and artificial
light may used
5. Preparation of Client:
• The nurse identify herself his to the client
• Explain the purpose for examination and
the procedures which may perform
• Explain the need for changing position during
examination asking the client if heshe has the
ability to do so
• Maintain the client privacy
• Provide the client with clean gown
6. Health history is the collection of
data regarding client’s health in a
chronological order.
7. COMPONENTS OF HEALTH HISTORY:
1. Biographical Information/ Base line data
2. Chief complaints
3. Present health history
4. Past health history
5. Family history
6. Personal history
7. Environmental history
8. Socio economic history
9. Psychological history
10.Review of systems
8. Health History
History Tacking
subjective data
Physical
Examination
Objective data
The nurse collects
- Physiological
- Psychological
- Socio-cultural
- Developmental
- Spiritual data
Page 49
9. Subjective data what the person says
about himself or herself.
Objective data what you observe through measurement,
inspection, palpation, percussion, and auscultation.
Types of data
10. • It should be performed on:
• All non-emergent
• New patients
• It include:
• all the component of health History.
Comprehensive
• It should be performed on:
• Emergency situation,
• patients under ongoing care.
• It include:
• Identification data
• Chief complaint and any
related family, social history.
• Problem oriented review
system
Focused
Types of health history
13. Use patient’s own words to describe reasons
for seeking care. (signs and symptoms)
Reason for seeking care
(chief complaint)
14. Present illness
Symptoms characteristics:
1. Location
2. Character or Quality
3. Quantity or Severity
4. Timing (Onset, Duration, Frequency)
5. Setting
6. Aggravating or Relieving Factors
7. Associated Factors
8. Patient’s Perception
15. Past history
Childhood Illnesses
Accidents or Injuries
Serious or Chronic Illnesses
Hospitalizations
Operations
Obstetric History (if female patient)
Immunizations
Last Examination Date
Allergies
Current Medications (Medication reconciliation)
16. Family history
An accurate family history highlights diseases and conditions
for which a particular patient may be at increased risk
This information is about,
• type of the family,
• number of members in the family, and
• their health status.
Ask about all disorders such as coronary heart disease, high
blood pressure, stroke, diabetes, obesity, blood disorders,
breast/ovarian cancer, colon cancer and sickle-cell anemia.
17. FAMILY TREE
• This is the diagrammatic representation of family
members.
• Three generation has to be denoted in the family
tree,
• Family tree is also known as genogram.
18.
19. Personal history
It includes client’s personal details such
as
• Dietary pattern
• Sleep pattern
• Elimination pattern
• Habits
• Bathing pattern
• Etc.
20. Environmental history
It includes client’s environmental details such
as,
• Type of the house
• Number of rooms
• Ventilation
• Water supply
• Power supply
• House drainage system
21. Socio economic history
It includes collecting data regarding
client’s
• Lifestyle
• Which class they belong
• What is the monthly or annual income
of the family
22. Psychological history
Here, We must see whether client is co-
operative with her/his
• Family
• Relatives
• Neighbors
• Friends
