6/11/2020 Comprehensive Assessment | Completed | Shadow Health
Comprehensive Assessment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
Return to Assignment
Your Results Lab Pass
Overview Self-Reflection Activity Time: 20 min
Transcript
Explicitly describe the tasks you undertook to complete this
Subjective Data exam.
Collection
Objective Data
Student Response: A comprehensive assessment is a complete, all-encompassing, in-depth
assessment that includes a complete health history and physical assessment. Components of the health
Collection
history are the patient's personal history of illness, as well as their family medical history, including any
current or prior treatments, surgeries, risk factors, and medications or supplements. In addition, it should
Documentation
include details of other aspects of health, such as the patient’s perception of their health, health beliefs,
coping mechanisms, support systems, and functional status. The first question I asked was for Tina to
Plan My Exam
verify her name and date of birth. This is a safety check that assures the assessment I am about to
conduct, is on the right patient. It also helps me to determine if this patient is alert to self. Another
Self-Reflection
important question that I started my interview process with was asking the patient the reason for her visit,
and if she had any health concerns she would like to discuss. This helps focus the attention on the patient
and what he or she needs or hopes to get out of the visit, and also helps guide the interview. Other
questions were based on the components of the health history mentioned earlier. For example, I asked
Tina how she felt she was doing, to get insight to her perception of health, which can help identify areas of
that Tina may need further education on. In addition, I asked Tina what her medical history was, what (if
any) medications (OTC, prescribed or supplements) she was currently taking and the reason for taking
them, and the dose and frequency. Aside from Tina’s health I asked questions about her personal life,
such as who she lived with, what her new job would be, relationship status, and what she enjoyed doing
for fun. Again, helping to develop a relationship with the patient, but also providing me with insight to her
functional status, support systems, and so on. Other questions asked pertained to risk factors or
unhealthy/unsafe behaviors. For example, asking Tina is she currently smoked, or used illicit drugs, or
had unprotected sex helps determine if she partakes in unhealthy/unsafe behaviors.
Once subjective data was collected, I performed the comprehensive physical assessment, which according
to Jensen (2015) should be a complete head-to-toe examination.
Head/Neck: I examined the patients head/face for general appearance, symmetry, expression, etc. I
assessed her skin, hair, and scalp. I estimated her eyes for equality, pupil response, eye movements, and
vision; her ears, nose, mouth, and throat. I palpated her lymph nodes and carotids. I tested her neck strength
and ROM.
Chest: I examined the patient's chest, in the following sequence, first anteriorly, then posteriorly. First I
inspected the pt position and appearance, to see if the patient appeared comfortable. Noting for any signs
of respiratory distress. Then I examined the patient's chest for symmetry, size, shape, and muscle use.
Next, I auscultated the patient's heart and lung sounds. After auscultation, I palpated PMI, and tactile
fremitus anteriorly, and palpated posteriorly for tactile fremitus, symmetry, and expansion and palpated for
CVA tenderness; Last, I percussed all lung fields.
Abdomen: I examined the patient's abdomen in the following order: inspection, auscultation, percussion,
https://www.coursehero.com/file/31663874/Comprehensive-Assessment-self-reflection-pdf/
https://chamberlain.shadowhealth.com/assignment_attempts/3569767 1/5
, 6/11/2020 Comprehensive Assessment | Completed | Shadow Health
and
palpation to
include the
general
appearance
of ( scars,
masses
striae, etc.)
symmetry,
shape, and
size.
https://www.coursehero.com/file/31663874/Comprehensive-Assessment-self-reflection-pdf/
https://chamberlain.shadowhealth.com/assignment_attempts/3569767 2/5
Comprehensive Assessment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
Return to Assignment
Your Results Lab Pass
Overview Self-Reflection Activity Time: 20 min
Transcript
Explicitly describe the tasks you undertook to complete this
Subjective Data exam.
Collection
Objective Data
Student Response: A comprehensive assessment is a complete, all-encompassing, in-depth
assessment that includes a complete health history and physical assessment. Components of the health
Collection
history are the patient's personal history of illness, as well as their family medical history, including any
current or prior treatments, surgeries, risk factors, and medications or supplements. In addition, it should
Documentation
include details of other aspects of health, such as the patient’s perception of their health, health beliefs,
coping mechanisms, support systems, and functional status. The first question I asked was for Tina to
Plan My Exam
verify her name and date of birth. This is a safety check that assures the assessment I am about to
conduct, is on the right patient. It also helps me to determine if this patient is alert to self. Another
Self-Reflection
important question that I started my interview process with was asking the patient the reason for her visit,
and if she had any health concerns she would like to discuss. This helps focus the attention on the patient
and what he or she needs or hopes to get out of the visit, and also helps guide the interview. Other
questions were based on the components of the health history mentioned earlier. For example, I asked
Tina how she felt she was doing, to get insight to her perception of health, which can help identify areas of
that Tina may need further education on. In addition, I asked Tina what her medical history was, what (if
any) medications (OTC, prescribed or supplements) she was currently taking and the reason for taking
them, and the dose and frequency. Aside from Tina’s health I asked questions about her personal life,
such as who she lived with, what her new job would be, relationship status, and what she enjoyed doing
for fun. Again, helping to develop a relationship with the patient, but also providing me with insight to her
functional status, support systems, and so on. Other questions asked pertained to risk factors or
unhealthy/unsafe behaviors. For example, asking Tina is she currently smoked, or used illicit drugs, or
had unprotected sex helps determine if she partakes in unhealthy/unsafe behaviors.
Once subjective data was collected, I performed the comprehensive physical assessment, which according
to Jensen (2015) should be a complete head-to-toe examination.
Head/Neck: I examined the patients head/face for general appearance, symmetry, expression, etc. I
assessed her skin, hair, and scalp. I estimated her eyes for equality, pupil response, eye movements, and
vision; her ears, nose, mouth, and throat. I palpated her lymph nodes and carotids. I tested her neck strength
and ROM.
Chest: I examined the patient's chest, in the following sequence, first anteriorly, then posteriorly. First I
inspected the pt position and appearance, to see if the patient appeared comfortable. Noting for any signs
of respiratory distress. Then I examined the patient's chest for symmetry, size, shape, and muscle use.
Next, I auscultated the patient's heart and lung sounds. After auscultation, I palpated PMI, and tactile
fremitus anteriorly, and palpated posteriorly for tactile fremitus, symmetry, and expansion and palpated for
CVA tenderness; Last, I percussed all lung fields.
Abdomen: I examined the patient's abdomen in the following order: inspection, auscultation, percussion,
https://www.coursehero.com/file/31663874/Comprehensive-Assessment-self-reflection-pdf/
https://chamberlain.shadowhealth.com/assignment_attempts/3569767 1/5
, 6/11/2020 Comprehensive Assessment | Completed | Shadow Health
and
palpation to
include the
general
appearance
of ( scars,
masses
striae, etc.)
symmetry,
shape, and
size.
https://www.coursehero.com/file/31663874/Comprehensive-Assessment-self-reflection-pdf/
https://chamberlain.shadowhealth.com/assignment_attempts/3569767 2/5
