Health Assessment: Health Assessment in Nursing

What does the “S” stand for in SOAP?
Subjective data
-health history obtained through questions and explanations
-information the patients relay to the healthcare provider

What does the “O” stand for in SOAP?
Objective data
-examination of body systems and expected findings
-what the healthcare provider sees in the examination

What does the “A” stand for in SOAP?
Assessment
-diagnosis

What does the “P” stand for in SOAP?
Plan

What falls into the category of “biological data”?
-name
-address
-phone number
-age/date of birth
-birthplace
-gender
-ethnic group
-race
occupation

Why is occupation an important aspect to know in the assessment of a patient?
to know whether or not there are factors at their job that could contribute to their diagnosis/interfere with their treatment

what are some important aspects to consider while talking to a patient and obtaining data from them?
who is giving the information, language barriers, use of interpreters, how reliable the informant is, how willing the informant is to tell you the correct information

What is another phrase for the term “reason for care”?
chief complaint

What is the “reason for care” or “chief complaint”?
a brief, spontaneous statement in the patients’ own words that describes the reason for the visit

how does the chief complaint differ between well patients and ill patients?
well patient: short statement of the general state of health
ill patient: chronological record of reason for seeking care

What does the acronym OLD CART stand for?
O- onset
L- location
D- duration
C- characteristics
A- associated manifestations/symptoms
R- relieving factors
T- treatments

What does the “O” in OLD CART stand for?
onset
-when did it start?

What does the “L” in OLD CART stand for?
location
-where is it occurring? (ex: cough- chest, abdominal pain- abdomen)

What does the “D” in OLD CART stand for?
duration
-has this happened before?

What does the “C” in OLD CART stand for?
characteristics
-characteristics of the symptoms (ex: wet or dry cough)

What does the “A” in OLD CART stand for?
associated manifestations/symptoms
-do any other symptoms occur at the same time? (ex: itchy, watery eyes along with the cough)

What does the “R” in OLD CART stand for?
relieving factors
-nursing measures (ex: cold compress on itchy eyes)

What does the “T” in OLD CART stand for?
treatments
-medications that work to relieve the symptoms

What health questions should be asked in regards to the past?
-childhood illnesses
-accidents
-past operations
-last examination date
-allergies
-current medications

Why is family health history important?
reoccurring illnesses in family history could be indication of a possible diagnosis

Review of systems: general
weight loss or gain, fatigue, weakness

Review of systems: skin
rashes, lumps, sores, itching, dryness, lesions

Review of systems: hair and nails
loss of hair, change in texture, change in nail color

Review of systems: head
headaches, dizziness, history of head injury

Review of systems: eyes
difficulty with vision, watering, dryness, discharge

Review of systems: ears
problems with hearing, use of hearing aids

Review of systems: nose and sinuses
frequent colds or sinus infections, nosebleeds, allergies, change of smell (sign of dementia)

Review of systems: mouth and throat
condition of teeth and gums, last dental exam, frequent sore throats

Review of systems: neck
any lumps or swollen glands

Review of systems: breasts
any lumps, pain, nipple discharge, last mammogram

Review of systems: axilla
any lumps, tenderness, rash

Review of systems: respiratory system
cough, wheezing, shortness of breath, pain with breathing, history of any lung disorder (asthma)

Review of systems: cardiovascular
chest pain, murmur, palpitations

Review of systems: peripheral vascular
leg cramps, history of clots, varicose veins

Review of systems: gastointestinal
appetite, nausea, vomiting, what’s your diet like? (24 hour recall)

Review of systems: urinary
frequency, urgency, burning

Review of systems: male genitalia
penis/testicular pain, discharge

Review of systems: female genitalia
menstrual history, bleeding between periods, menopause

Review of systems: sexual health
current relationship, intercourse, satisfaction, pain, contraception, concerns about STDs

Review of systems: musculoskeletal system
muscle or joint pain, stiffness, swelling

Review of systems: neuro
fainting, seizures, blackouts, paralysis

Review of systems: psyche
anxiety, depression, past mental health problems

Review of systems: hematologic
anemia, easy bruising or bleeding, transfusion history

Review of systems: endocrine
history of diabetes, history of thyroid disease

What consists of the functional assessment?
-sleep/rest
-exercise/activity
-nutrition/elimination
-spiritual resources
-personal habits: smoking, drinking, drugs

Why is it important to know whether or not the patient is using recreational drugs?
because the medication being prescribed could be more harmful than good if it reacts to the recreational drugs being used

What is important to establish when working with children or adolescents?
-developmental stages of the child, whether or not they developed relatively normal
-nutrition
-mother’s health during pregnancy, labor, delivery and perinatal care

What is different while working with pediatrics than it is in children or adolescents?
prenatal history is also important for pediatrics

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