1general 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
2components of general survey (4)
physical appearance, body structure, mobility, behaviour
3behaviour (3)
-LOC
-note speech
-facial expression
4physical appearance (5)
-overall appearance
-breathing
-hygiene and dress
-skin colour and lesions
-body structure an ddevelopment
5mobility (4)
-posture
-ROM
-gait (manner of walking)
-position of comfort
6orientated x3
they know who they are, where they are, and the approximate time
7initial data includes
anthropometric measurements and vital signs
8anthropometric measurements
height, weight, BMI
(changes? medication dosages, first sign of endocrine disorder)
9objectives 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
10components 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