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Comprehensive Nursing Assessment Guide

The document outlines guidelines for conducting a health history and physical examination in nursing. It discusses conducting an interview, collecting data on a patient's personal profile including their chief complaint and medical history, assessing functional status, reviewing systems, and documenting findings from a physical exam. The goal is to gather comprehensive information on a patient's health to inform an appropriate nursing diagnosis.

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990 views2 pages

Comprehensive Nursing Assessment Guide

The document outlines guidelines for conducting a health history and physical examination in nursing. It discusses conducting an interview, collecting data on a patient's personal profile including their chief complaint and medical history, assessing functional status, reviewing systems, and documenting findings from a physical exam. The goal is to gather comprehensive information on a patient's health to inform an appropriate nursing diagnosis.

Uploaded by

markkkkkkkheeess
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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I.

Review of the Nursing Process


II. Health History Guidelines
A. Interview
1. Purpose
2. Structure
3. Guidelines of an effective interview
III. Health History
A. Personal profile
1. Biographical Data
2. Chief complaint of present illness
a. Usual health status
b. Chronological story
c. Impact on functioning
d. Medications
3. Past health history
4. Current medications
5. Personal habits & patterns of living (ADL)
6. Psychosocial History
a. Mental Status Assessment
Children and Adolescent
Adults
B. Functional Assessment
1. Adults
2. Physical activities of daily living (PADC)
3. Instrumental activities of daily living (IADL)
C. Functional Assessment Tests
1. Newborns – Apgar scoring system
2. Infants & children – MMDST
3. Adults
a. Katz Index of Independence in ADL
b. Barthel index
D. Review of Systems (Symptoms)
E. Assessment in pregnancy (e.g. LMP, EDC)
F. Pediatric Additions to Health History (e.g. head circumference, weight,
height, immunization)
G. Geriatric Additions to the Health History (e.g. immunization, current
prescription medications, over the counter medications, ADL, social
support, etc.)
IV. Physical Examination
A. Preparation guidelines
B. PE guidelines
C. Techniques in Physical assessment
1. Inspection
2. Auscultation
3. Percussion
4. Palpation
D. Continuing Assessment
1. Pain
2. Fever
E. Pediatric Adaptation
1. General guidelines
2. Specific age groups
F. Geriatric adaptations
1. General guidelines
2. Modifications
G. Cultural considerations
1. Sequence of PE (adult/pedia/geriatric adaptations)
a. Overview
b. Integument
c. Head
d. Neck
e. Back
f. Anterior Trunk
g. Abdomen
h. Musculoskeletal system
i. Neurologic system
j. Genitourinary system
H. Clinical alert
I. Documentation of findings
J. Patient & Family Education & Home Health Teaching
V. Diagnostic Tests (routine laboratory exams)
VI. Appropriate Nursing Diagnosis

Chief Complaint

Present Problem

a. Usual health status


b. Chronological story
c. Impact on functioning
d. Medications

Past Medical History

Family History

Personal & Social History

Review of Systems or Functional Patterns

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