Comprehensive health assessment
An in-depth assessment of the whole person, including physical, mental,
emotional, cultural, and spiritual aspects of a patient's health.
The very first assessment (admission assessment usually done by RN)
Focused assessment
When we examine or review specific body systems or two. Quick diagnosis and
treatment.
Initial head-to-toe shift assessment
A quick overall assessment of the patient's condition and whole body to
establish a baseline
When to perform a comprehensive assessment?
On admission. The first assessment in the facility was completed by an RN.
When to perform a head-to-toe assessment?
At the beginning of each shift
When to perform an assessment?
When the patient's condition changes, when evaluating the effectiveness of
nursing care, and whenever something doesn't feel right.
Signs
use of the four senses (see, hear, smell, touch).
Produces objective and measurable evidence
Symptoms
evidence of illness of injury that is verbalized by the patient.
the findings are subjective
Subjective technique for physical assessment
, Interview
Objective technique for physcial assessment
inspection, percussion, auscultation, palpation, olfaction
Inspection
observation, visual
Percussion
physically tap or "hit"
Auscultation
hearing (stethoscope)
Palpation
feeling and touch
Olfaction
sense of smell
PERRLA
pupils are equally reactive and round to light (accomodation: focus on a fixed
area)
Orientation
person, place, time
0+ edema
no pitting edema
1+ edema
mild pitting edema. 2 mm depression that disappears rapidly
2+ edema
moderate pitting edema. 4mm depression that disappears in 10-15 seconds.
3+ edema
An in-depth assessment of the whole person, including physical, mental,
emotional, cultural, and spiritual aspects of a patient's health.
The very first assessment (admission assessment usually done by RN)
Focused assessment
When we examine or review specific body systems or two. Quick diagnosis and
treatment.
Initial head-to-toe shift assessment
A quick overall assessment of the patient's condition and whole body to
establish a baseline
When to perform a comprehensive assessment?
On admission. The first assessment in the facility was completed by an RN.
When to perform a head-to-toe assessment?
At the beginning of each shift
When to perform an assessment?
When the patient's condition changes, when evaluating the effectiveness of
nursing care, and whenever something doesn't feel right.
Signs
use of the four senses (see, hear, smell, touch).
Produces objective and measurable evidence
Symptoms
evidence of illness of injury that is verbalized by the patient.
the findings are subjective
Subjective technique for physical assessment
, Interview
Objective technique for physcial assessment
inspection, percussion, auscultation, palpation, olfaction
Inspection
observation, visual
Percussion
physically tap or "hit"
Auscultation
hearing (stethoscope)
Palpation
feeling and touch
Olfaction
sense of smell
PERRLA
pupils are equally reactive and round to light (accomodation: focus on a fixed
area)
Orientation
person, place, time
0+ edema
no pitting edema
1+ edema
mild pitting edema. 2 mm depression that disappears rapidly
2+ edema
moderate pitting edema. 4mm depression that disappears in 10-15 seconds.
3+ edema
