Week 2: Collecting Data and Health Assessment Techniques

General Survey

Initial assessment of patient appearance and behavior.

Level of Consciousness (LOC)

Assessment of awareness using person, place, time.

Anthropometric Measurements

Height, weight, and BMI calculations for health assessment.

Vital Signs

Indicators of health status and body function.

Blood Pressure (BP)

Average 120/80; influenced by various factors.

Heart Rate

Normal range 60-100 beats per minute.

Respiratory Rate

Measured for ease or struggle in breathing.

Temperature

Normal range 35.9°C to 38.1°C.

Pediatric Assessment

Tracks development percentiles and health concerns.

Daily Weights

Monitored for changes in cardiac/renal patients.

BMI

Body Mass Index; weight relative to height.

Framingham Risk Score

Predicts cardiac event risk over 10 years.

Nutrition Status

Assessed through appetite, intake, and hydration.

Dehydration Signs

Cracked lips, no urine, vomiting bile.

Health Interview

Foundation for gathering patient care information.

Subjective Data

Information reported by the patient.

Primary Data Source

Patient as the main source of information.

Secondary Data Sources

Family, charts, and other professionals' insights.

Health Interview Planning

Establish goals and prepare for patient interaction.

Demographic Data

Confirms patient identity and background.

History of Present Illness

Details symptoms using 10 attributes.

Sensitive Topics

Discuss alcohol, drugs, and mental health non-judgmentally.

Cultural Considerations

Cultural beliefs affecting health perceptions.

Environmental Considerations

Safety and exposure factors impacting health.

10 Attributes of Symptoms

Includes location, timing, severity, and patient perspective.

Review of Systems

Assessment of 14 different body systems.

Constitutional Symptoms

Overall presentation of the patient's health.