Health History, General Survey, and Vital Signs Notes (PDF)

***Week 1 notes: Health history, General survey, and Vital signs*** ***Chapters 1,5, 10*** Learning outcomes: Answers 1. Discuss the role of assessment as the starting point of all models of clinical reasoning. 1. Assessment is foundational to nursing and clinical reasoning bec...

***Week 1 notes: Health history, General survey, and Vital signs*** ***Chapters 1,5, 10*** Learning outcomes: Answers 1. Discuss the role of assessment as the starting point of all models of clinical reasoning. 1. Assessment is foundational to nursing and clinical reasoning because it involves systematically gathering data to understand the patient\'s health status. A thorough assessment ensures respect for the individual and their unique context, avoiding objectification. It is essential for confidence in clinical abilities and the capacity to respond effectively to patients\' needs. 2. Describe the use of diagnostic reasoning in clinical judgement. 2. Diagnostic reasoning involves analyzing and interpreting data from the patient\'s history and physical examination to identify health problems or conditions. This reasoning is critical for forming judgments and determining appropriate interventions. It combines clinical expertise, evidence-informed guidelines, and patient-specific factors​. 3. Explain the use of the nursing process in clinical judgement. The nursing process incorporates a systematic method for providing care: 3. **Assessment**: Gathering subjective and objective data. 4. **Diagnosis**: Identifying health problems based on the assessment. 5. **Planning**: Setting goals and outcomes. 6. **Implementation**: Providing care and interventions. 7. **Evaluation**: Reviewing outcomes and modifying the plan as needed 4. Describe the purpose of the complete health history and understand its components. The complete health history aims to collect subjective data, forming the database for clinical judgment. It includes: 8. **Biographical Data** 9. **Reason for Seeking Care** 10. **Current Health or History of Current Illness** 11. **Past Health History** 12. **Family Health History** 13. **Review of Systems** 14. **Functional Assessment**, including Activities of Daily Living (ADLs)​ 5. Describe the four types of databases that the nurse uses in practice: Complete (Total Health), Episodic or Problem-Centred, Follow-Up and Emergency. Nurses use the following types of databases: 15. **Complete (Total Health)**: Comprehensive health history and physical exam. 16. **Episodic or Problem-Centered**: Focused on a specific issue or problem. 17. **Follow-Up**: Monitoring progress of a condition or treatment. 18. **Emergency**: Rapid collection of critical data during urgent situations​ 6. Discuss differences of obtaining a health history from different age groups. Differences in obtaining a health history depend on age: 19. **Children**: Focus on developmental history and milestones. 20. **Adolescents**: Address psychosocial aspects and emerging independence. 21. **Older Adults**: Emphasize functional status, chronic conditions, and adaptation to aging 7. List the information considered in each of the four areas of a general survey. A general survey encompasses: 22. **Physical Appearance**: Age, sex, level of consciousness, and skin condition. 23. **Body Structure**: Stature, nutrition, symmetry, and posture. 24. **Mobility**: Gait and range of motion. 25. **Behavior**: Facial expression, mood, speech, and personal hygiene 8. Review various routes of temperature measurement and understand special consideration for each route review for the four qualities considered when assessing the pulse. 26. **Oral**: Convenient, standard for most patients. 27. **Rectal**: Accurate but invasive; use for infants or unconscious patients. 28. **Axillary**: Less accurate, but non-invasive. 29. **Tympanic and Temporal**: Quick and non-invasive but may vary due to external factors​ 9. Identify common errors in taking a temperature and pulse. 30. **Temperature**: Failing to wait after eating, drinking, or smoking; incorrect probe placement. 31. **Pulse**: Miscounting beats, applying excessive pressure, or failing to note irregularities​ 10. Describe the appropriate procedure for assessing normal respirations and variations for different age groups. Observe the rise and fall of the chest without the patient\'s awareness to avoid altered breathing patterns. Note rhythm, depth, and effort: 32. **Infants**: Observe abdominal movements. 33. **Older Adults**: Account for reduced lung elasticity 11. Appreciate the relationships between the terms blood pressure and pulse pressure. 34. Blood pressure comprises systolic and diastolic measurements. Pulse pressure, the difference between them, reflects the stroke volume and arterial elasticity. High or low pulse pressure can indicate cardiovascular health​