Survey

Assessment

The process of gathering information about a patient's health status through observation, interviews, and physical examinations.

Therapeutic communication

Communication techniques used by healthcare providers to establish trust, build rapport, and promote a supportive environment for patients.

Nonverbal body language

Communication expressed through gestures, facial expressions, posture, and eye contact, which can convey emotions and intentions.

Cues

Verbal or nonverbal signals from the patient that provide information or indicate a need for clarification or further communication.

Emotional state

The patient's current emotional well-being, which can impact their overall health and response to treatment.

Introduce yourself

The act of informing the patient of your name and role as a healthcare provider, as well as asking for their name and date of birth for identification purposes.

General Inspection

The initial assessment of a patient's physical appearance, including their clothing, hygiene, body structure, movement, mental status, and behavior.

Objective assessment

Direct assessment techniques such as inspection, percussion, palpation, and auscultation used to gather information about a patient's health status.

Subjective assessment

The information provided by the patient in response to questions about their symptoms, feelings, and experiences.

Behavior assessment

The evaluation of a patient's speech, mood, facial expressions, and overall behavior to assess their mental and emotional well-being.

Indications of abuse, neglect, or human trafficking

Signs or behaviors that may suggest a patient is experiencing mistreatment, including fear, avoidance of eye contact, unusual dress, presence of old injuries, or difficulty walking.

Posture

The position and alignment of the body, including the spine and limbs, which can provide information about a patient's physical condition and comfort level.

Facial expressions

The movements and positions of the muscles in the face that convey emotions, reactions, and overall well-being.

When does assessment begin

at first sight

After you introduce yourself, you ask for their

name and DOB

eye contact

wondering eyes, no eye contact, nervous

Orientation: person

knows their name and significant others

Orientation: person and place

understands where they are

Orientation: person, place, time

date, day, season

Orientation: person, place, time , situation

can explain why they are at a healthcare facility

Stadiometer

standing scale

1 kg

2.2 pounds

Underwieght

18.5 kg

Overweight

25-30 kg

Average temperature

98.6

Fever Temperature

over 100.4

Pallor

white

Cyanosis

blue tint - lack of O2

Jaundice

yellow - liver problems

Erythemia

Redness

Cachectic

can see ribs/bones

Crepitus

cracking sounds when in motion

spasticity

alteration of muscle tone

Rigidity

resistance

Myoclonous

sudden jerking

Tic

involuntary motion - neuro issues

Termors

alteration of muscle groups

Assessment Checklist

height, weight, bmi, vitals, pain, check for a baseline

Hypoxia

RR less than 90

Adult RR

12 -20

Bradypnea

less than 12

Normal BP

120/80

Hypotension

less than 90 diastolic

Medication that can decrease BP

cardiac and opioids

Medication that can increase BP

vasoconstrictors

Head Circumference of a baby

32-38 cm at birth