The complete health assessment

The complete health assessment

• enter room

• provide privacy

• hand hygiene

• obtain correct equipment for nursing assessment

Complete physical assessment: neonate and infant

generally and relative to a healthy adult patient

• increased heart rate

• increased respiratory rate

• lack of hemodynamic reserve

Older adult functional assessment

• 65 years old or greater

• geriatric assessment (comprehensive)

Older adult functional assessment: activities of daily living (ADL’s)

• functional status → ability to perform ADLs

• independent, with assistive device, assistance, etc.

• ask and observe

Examples of ADLs

• bathing/hygiene

• dressing

• eating/feeding

• grooming

• toileting

• walking/ambulation/transfers/mobility

Instrumental activities of daily living (IADL’s)

tasks required for independent living in the community

Examples of IADLs

• financial management

• housekeeping

• laundry

• medication administration

• meal preparation

• shopping

• transportation

Cognition assessment

alterations associated with dementia, delirium, depression

Delirium

acute change in cognition

Primigravida

pregnancy for the first time

Primipara

term describing patient for post delivery of first pregnancy

Multigravida

pregnancy for patient who has been pregnant previously

Multipara

post delivery in setting of multiple pregnancies

Pregnancy

• presumptive signs

• probable signs

• positive signs

Presumptive signs

• amenorrhea

• breast tenderness

• fatigue

• nausea

• urinary frequency increased

Amenorrhea

missed periods

Probable signs

• examiner detection on assessment

• example → enlarged uterus

  • potential for palpation on physical examination → approximately 12 weeks

Positive signs

• direct evidence of fetus

• example of + fetal heart tones (FHT)

2nd trimester of pregnancy

colostrum → so-called precursor of breastmilk → expressed via nipple

3rd trimester of pregnancy

observation of progressive lordosis

Determination of gestation: nagele’s rule

• estimated date of delivery (EDD)

• 280 days from first day of patient’s last menstrual period (LMP)