Health Care Process Overview

The process of gathering, organizing, verifying, and recording information about a client's health status.

A comprehensive overview of a client's health, including medical history, physical assessment, and lab results.

Information collected to focus on a specific health issue or condition.

Information provided by the client about their feelings, sensations, and perceptions.

Observable and measurable information about a client's health.

The person providing information about their own health. This is typically the patient or client.

Information from family members, other healthcare providers, medical records, or literature.

The process of obtaining information about a client's health. This can include observation, interviews, and physical exams.

A patient position with the head of the bed raised between 15° and 45°, typically at 30°. Promotes lung expansion and relieves pressure on the sacrum and heels.

A patient position with the head of the bed lowered and the foot raised in a straight incline. Promotes venous circulation and postural drainage of basal lung lobes.

A patient position lying flat on their back with the knees flexed. Provides comfort and is ideal for examination of the abdomen.

A patient position with legs placed on stirrups, primarily used for rectal or vaginal examinations and childbirth. Requires careful placement to avoid nerve pressure.

A patient position where the person kneels with their face flat on the bed. Helpful for relieving severe abdominal pain, dysmenorrhea, and other internal discomfort.

A patient position with the head of the bed elevated and the feet lowered. Helpful for managing gastrointestinal issues and preventing esophageal reflux.

Covers used to protect patient privacy, provide warmth, and facilitate examination. Made of paper, cloth, or linen. Sterile drapes are used during surgical procedures.

All equipment for health assessment should be clean, in good working order, and readily accessible. Often set up on trays for easy use.

Back lying position with legs extended and arms at sides. Suitable for abdominal examinations and inspecting for lumps or breast masses.

Lying on your stomach, face turned to the side. Used for examinations of the back, spine, and hip joint movements.

Side lying position with lower arm behind body, uppermost leg bent, and upper arm flexed. Allows for drainage of mucus and is used for examining the vagina, rectum, performing enemas, and inserting suppositories.

Back lying position with feet supported in stirrups. Used for examining the female genitals, rectum, and the reproductive tract. Can be uncomfortable for elderly or patients with limited mobility.

Lying on your side with the top leg in front of the bottom leg, both bent at the knees and hips. Used for examining the lungs and chest.

The position of a patient lying on their back with a pillow placed under their shoulder, allowing for better examination of the chest and breasts.

Back lying position with arms at sides and legs slightly bent at knees. Often used for general physical examinations and blood pressure measurements.

Back lying position with legs flat and slightly elevated. Often used for examinations of the cardiovascular system.

A medical instrument used to listen to the sounds of the heart, lungs, and other internal organs. It consists of a diaphragm, a bell, tubing, and earpieces.

A medical instrument used to examine the inner part of the eyeball, including the retina and optic disc.

A medical instrument used to measure blood pressure. It consists of a cuff, a bulb, and a gauge.

A medical instrument used to examine the ear. It consists of a light source, a magnifying lens, and a speculum.

A medical instrument used to examine the mouth and throat. It is a flat, wooden or plastic depressor.

A medical instrument used to examine the larynx, the voice box. It consists of a handle, a blade, and a light source.

A medical instrument used to test reflexes. It consists of a rubber hammer with a head.

A medical instrument used to test hearing. It is a metal fork that vibrates.

A safe and quick imaging technique that uses sound waves to create images of internal organs.

The images produced by an ultrasound.

Used to examine reproductive organs by inserting the probe into the vagina.

Type of ultrasound that provides a clearer view of the fetus in the first trimester.

Used to examine organs from outside the belly.

Gel applied to the abdomen to help transmit sound waves.

A device that sends out sound waves and receives the echoes to create images.

More advanced ultrasound technology that creates detailed images.

A test that involves collecting and examining a sample of mucus from the lungs and airways to diagnose respiratory conditions.

A blood test that measures the number of red blood cells, white blood cells, and platelets in the blood.

The process of determining an individual's blood type.

A type of blood that contains both A and B antigens.

A type of blood that contains only B antigens.

A type of blood that contains only A antigens.

A type of blood that contains neither A nor B antigens.

A test that examines a sample of stool to diagnose digestive conditions.