Health Assessment Exam 1

percentage of History (subjective data)

70%

percentage of Physical Examination (objective data)

20%

percentage of Laboratory/ Imaging Studies (Objective data)

20%

Subjective Data

pain when applying pressure, blurry vision x 5 days, and dizzy when standing up

Objective Data

raised purple lump on forehead, unable to read vision chart past 2nd line, blood pressure drops when standing up

symptom

what the patient feels/ communicates (subjective)

sign

clinical findings collected during physical examination (objective)

clinical manifestations

sings and symptoms collected

what are the three levels of health promotion

primary, secondary, and tertiary

primary

preventing disease from developing through promoting healthy lifestyles

secondary

screening efforts to promote early detection of disease

tertirary

minimizing disability from acute or chronic illness or injury and allowing for most productive life within limitations

health history

is a subjective data from the patient, if they are able to provide. sometimes it will come from a significant other. persons past and present health

therapeutic communication

single most important factor for successful interviewing

examples of therapeutic communication

active listening, clarifying, open ended questions, and slience

non- therapeutic communication

using medical terminology without defining, why questions, interrupting, false reassurance

professional communication

health literacy and appropriate use of medical terminology

environment/ physical setting

quiet, private, free from interruptions, and comfortable room temperatures.

patient comfort

watch nonverbal cues, don’t make promises, listen to the patient, tell patient what you are doing to do, watch signs of fatigue and stop at first signs

professional behavior

calm, organized, competent, professional attire, proper hygiene, warm hands, PPE

biographical information

name, age, gender, occupation

O

onset

L

location

D

duration

C

character nature of pain

A

aggravating alleviating factors

R

relieving factors

T

temporal factors- occurence —> chronic, intermittent, acute

S

severity-scale, effect on life

onset

when did the symptoms first start

location

point to spot where it hurts or describe

duration

chronological; how long have you had them and how long do they last

Character

describe the sensation or appearance to the best of the patients ability

Associated Factors

what makes the symptoms worse or better

Relieving Factors

what relieves symtoms? medication, ice pack

temporal/ treatment

frequency of occurence -single attack vs intermittent

Severity

size, extent, number amount grade scale 1-10

Auscultation

listenting with a stethoscope