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Health Assessment

Health Assessment. Nursing Assessment. Health history Physical exam. Nursing History. Patient profile Chief complaint Past history Family history Medications Allergies Review of systems. Pain. Location Length of time Severity Quality. Nursing History. Patient profile

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Health Assessment

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  1. Health Assessment

  2. Nursing Assessment • Health history • Physical exam

  3. Nursing History • Patient profile • Chief complaint • Past history • Family history • Medications • Allergies • Review of systems

  4. Pain • Location • Length of time • Severity • Quality

  5. Nursing History • Patient profile • Chief complaint • Past history • Family history • Medications • Allergies • Review of systems

  6. Methods of Examination • Inspection • Palpation • Light • Deep

  7. Percussion • flatness • dullness • resonance • hyperresonance • tympany

  8. Auscultation • pitch • intensity • duration • quality

  9. Stethoscope

  10. General Survey • Age, sex, race • Body build, height, weight • Posture and gait • Hygiene and grooming • Signs of Illness • Affect • Cognitive Processes

  11. Skin • Color • Vascularity • Lesions • Temperature • Turgor • Texture • Wounds

  12. Clubbing of Fingernails

  13. Inspect scalp and hair Facial Symmetry Palpate SinusesEyes Ears Inspect Nose Mouth Neck ROM Lymph Nodes Palpate trachea Palpate carotids Auscultate carotids Assess for JVD Head and Neck

  14. Cardinal Fields of Gaze Return to Head and Neck

  15. Oropharynx Return to Head and Neck

  16. Return to Head and Neck Slide

  17. Sinuses Return to Head and Neck

  18. Measuring JVD

  19. Chest: Lungs • Respirations • labored • unlabored • Chest shape • Chest symmetry • Breath sounds

  20. Cardiac Circulation

  21. Breast Exam Techniques

  22. Documenting the Breast Exam

  23. Abdomen • Contour • Size • Bowel sounds • Tenderness • Palpate bladder

  24. Extremities • ROM present • Strength • Capillary refill • Peripheral pulses • Edema • Nails

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