This exam also includes: These can include a complete blood count and a complete metabolic panel also called a chemistry panel. The panel tests your blood plasma and can indicate any issues that exist in your kidneys, liver, blood chemistry, and immune system. This helps detect irregularities in your body that might indicate a larger problem.
The interplay between the physiology of aging and pathologic conditions more common in the aged complicates and delays diagnosis and appropriate intervention, often with disastrous consequences. This chapter assumes that practitioners will perform the thorough history and physical examination that is expected of an excellent general internist.
It highlights the special considerations required for the older adult. History General considerations The history may take more time because of sensory or cognitive impairment or simply because an older patient has had time to accrue numerous details. Several sessions may be required.
The patient should be recognized as the primary source of information. If doubts arise about accuracy, other sources should be contacted with due respect paid to the sensitivities and confidentiality of the patient.
When interviewing the patient and caregiver together, ask questions first to the patient, then to the caregiver. If the patient's responses to initial questions are clearly inappropriate, turn to the mental status exam immediately. The patient should be dressed and seated.
The physician should also be seated and facing the patient at eye level, speaking clearly with good lip movement. If the patient is severely hearing impaired and an amplifier is not available, write questions in large print. Areas requiring special emphasis Function-- see Functional Status Assessment Pay attention to deficits in basic and instrumental activities of daily living ADL.
Prepare to assess those systems in the physical examination, looking for reversible conditions that could upgrade function, e.
Polypharmacy and excessive dosages are common causes of iatrogenic illness. A "paper bag" test is often useful to explore this possibility, i. Be sure to include over-the-counter OTC preparations. Review of systems--Cardiovascular illness is the major cause of death in older adults and these systems should be investigated thoroughly.
Of particular importance also are: Assessment of lifestyle, affect, ognition, function, values, health beliefs, cultural factors and caregiver issues is also important. Consultation with a social worker in obtaining this information and adapting the care plan is often critical but the initial identification of need for such consultation is part of the primary care evaluation.
Nutritional history-- see Nutritional Assessment and Treatment Strategies.
Performing the basic nutritional assessment will identify patients at risk of malnutrition and in need of referral for dietetic consultation. Physical Examination General considerations Limit the time the patient is in the supine position as this may cause back pain for persons with osteoarthritis or kyphoscoliosis and shortness of breath for those with cardiopulmonary disease--having several pillows on hand for these patients will be greatly appreciated.
Multiple sessions may be required for a complete physical exam due to patient fatigue.
While they are important, the rectal and pelvic exams may be deferred to a later session, if not urgently required. Signs of ADL deficits, poor hygiene, disheveled appearance. Rectal temperature if patient is seriously ill because of blunted immune response see Infectious Diseases.The physical exam is a chance for a frank discussion about health, habits, and your future.
With your doctor’s help, you’ll be able to tackle signs of potential problems with a plan. Nursing assessment is an important step of the whole nursing process. Assessment can be called the “base or foundation” of the nursing process.
With a weak or incorrect assessment, nurses can create an incorrect nursing diagnosis and plans therefore creating wrong interventions and evaluation.
Health Assessment Physical Assessment Documentation Form Date: __3/1/16_____ Patient Information Patient Initials BR Age 30 Sex Female General Survey Does patient appear to be their stated age?
Yes Level of consciousness Alert and Oriented to person, place and time. Overview of Nursing Health Assessment This course has been awarded two () contact hours.
This course will provide the nurse with the knowledge needed to provide a complete health assessment for an adult patient.
After successful completion of this course, you will be able to: physical assessment can be completed within a time frame. Expanded chapter on assessment of the hospitalized adult provides a focused assessment of the patient in the hospital setting.
New content on obesity provides current information on this growing health . MHC (Rev ) Initial Clinical Assessment for Adults Page 1 of Initial Clinical Assessment for Adults. Health Care 58 IntSvcs: MH / Aging 61 Age-Spec Svc Strategy 99 Unknown Employment / School Performance Physical Health Recreational / Leisure Activities Substance Abuse.