2a General Survey, HH, Initial Data

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1
general survey (3)
-Begins with the first moment of the encounter with the patient and continues throughout the health history
-Is the first component of the assessment
-qHelps to form a global impression of the person
2
components of general survey (4)
physical appearance, body structure, mobility, behaviour
3
behaviour (3)
-LOC
-note speech
-facial expression
4
physical appearance (5)
-overall appearance
-breathing
-hygiene and dress
-skin colour and lesions
-body structure an ddevelopment
5
mobility (4)
-posture
-ROM
-gait (manner of walking)
-position of comfort
6
orientated x3
they know who they are, where they are, and the approximate time
7
initial data includes
anthropometric measurements and vital signs
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anthropometric measurements
height, weight, BMI
(changes? medication dosages, first sign of endocrine disorder)
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objectives of the health history (4)
gain foundation of information to guide client care
-establish therapeutic relationship with patient and family
-introduce client to health care facilities
-gain insight about concerns
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components of the health history (11)
-demographic data
-chief concern
-history of present illness (LATERSNAPS)
-past health history/allergies & response
-current medications & indications
-family history
-personal and social history
-functional health questions (gordon's framework, ADLs)
-growth & development
-review of body systems
-psychosocial factors
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