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NR 302 Week 1 Edapt
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NR 302 Week 1 EdaptIntroduction to Health Assessment
The complete health assessment includes a health history, physical assessment, and interpretation of data to
determine if further assessment is needed.
Although the information collected during the complete health assessment is used to set goals for the client’s
health and identify teaching needs, those aspects of care are not part of the complete health assessment.
Health History
o What prompted you to seek care today?
o How long have you been feeling unwell?
o What prescribed and over-the-counter medications or supplements are you currently taking?
o Are you having any challenges obtaining your medications or other items needed to care for
yourself?
o Do any chronic illnesses run in your family?
o Do you have specific dietary practices we can support while you are here?
o Are you able to purchase healthy food near your home?
o Do you have any concerns or challenges caring for yourself at home?
Physical Assessment
o Are you having any chest pain or tightness?
o How is your vision?
o Have you noticed any changes in your level of energy?
o How often do you normally have a bowel movement?
o Would you like another person to be present while I complete your physical examination?
Types of Health Assessments
Rapid
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, Purpose: Determines the urgency of the client’s condition
When used: Each time the client is seen
Includes: Level of consciousness, ease of breathing, and body position
Examples:
Urgent: The examiner finds a person in a hospital gown sitting on the floor gasping for air.
Not Urgent: The examiner observes the client speaking complete sentences on the phone with
even respirations.
Complete (Total _ Health
Purpose: Establishes the medical database for an episode of care
When used: At the first interaction between a person seeking care and the professional providing care
Includes: A detailed health history and physical examination of all body systems
Examples include the first visit to a new healthcare provider or new admission to a long-term care
facility.
Focused (Problem Centered)
Purpose: To obtain more data about specific concerns or abnormal findings related to a body system
When used: After abnormal findings are identified during any assessment
Includes: The collection of data related to findings of concern
Example: After noting a client’s productive cough and shortness of breath when entering the room, the
examiner begins the assessment by listening to lung sounds, measuring oxygen saturation (O2 sat),
checking for cyanosis, and asking questions related to the noted symptoms (e.g., How long has the
cough been present?).
Follow-up
Purpose: To determine effectiveness during or after treatment
When used: Timing depends on the situation
Includes: A focused assessment used to evaluate how the client is responding to treatment
Examples: Checking on a client 30 minutes after administering pain medication or a follow-up office
visit with a primary care provider to determine the effectiveness of blood pressure medication
Emergency
Purpose: Collection of key data during an urgent or emergent medical situation
When used: When an individual is facing a life-threatening situation
Includes: Assessment of the Airway, Breathing, Circulation, Disabilities, and Exposure (ABCDE)
This study source was downloaded by 100000864769797 from CourseHero.com on 08-25-2023 11:24:50 GMT -05:00
https://www.coursehero.com/file/210246046/NR-302-Week-1-Edaptdocx/
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