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Comprehensive Patient Assessment - Coggle Diagram
Comprehensive Patient Assessment
Health history
Medical, surgical (incl anaesthetic hx), family.
Use of medication - chronic, OTC or recreational
Social hx - smoking (how much), drinking
Cultural considerations
Objective data
Signs
Are observable / measurable / can be tested against a set standard
Observation by nurse, physical exam, diagnostic + lab findings, vital data
Sources
Pt records, lab results, health care professionals, literature
Subjective data
Symptoms
Apparent only to person affected
Pt sensations, feelings, values, beliefs, attitudes and perceptions
Sources
The patient + family / friends
Physical examination
Purpose
To obtain baseline data
To supplement, confirm or refute data obtained in the nursing history
To obtain data that will help establish nursing diagnoses and care plans
To evaluate physiological outcomes of health care and patient progress
To make clinical judgements about pts health status
To identify areas for health promotion and disease prevention
Head to toe framework
General survey
Vital signs
Head
Neck
Upper extremeties
Chest and back
Abdomen
3 more items...
Skin, chest shape, size and movement, lungs
Heart, spinal column, breasts + axillae
Skin, nails, muscle strength + tone, joint ROM
Brachial + radial pulses, sensation
Muscles, lymph nodes, trachea
Thyroid gland, carotid arteries, neck veins
hair, scalp, face
Eyes + vision
Ears + hearing
Nose + smell
Mouth + oropharynx
Cranial nerves x 12
BP, PR, RR, Temp, SpO2, Urine analysis, HGT
(height and weight)
Appearance
Mental status
Assessment techniques
Inspection
Palpation
Percussion
Auscultation
Health assessment
Current health problem, duration, previous treatment, signs and symptoms, progress
Biographic data - Name, age, gender, occupation, marital status, housing