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Initial assessment is conducted when patient arrives for the first time in
inpatient department (IPD), outpatient department (OPD), and
emergency department (ED)).
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3-History of present illness
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Component of Present Illness
Introduction: "client's summary and usual
health".
Investigation of symptoms: "onset, date,
gradual or sudden, duration, frequency,
location, quality, and alleviating or
aggravating factors".
Negative information.
Relevant family information.
Disability "affected the client's total life".
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4- Past Health History:
The purpose: (to identify all major past
health problems of the client)
This includes:
Childhood illness e.g. history of
rheumatic fever.
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Past Health History. Cont…
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Family History. Cont…
Includes :
How client and his family cope with
disease or stress, and how they responses
to illness and health.
You can assess if there is psychological
or social problem and if it affects general
health of the client.
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9- Review of Systems (ROS)
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Physical Systems
Which includes assessment of:-
General review of skin, hair, head, face, eyes, ears,
nose, sinuses, mouth, throat, neck nodes and breasts.
Assessment of respiratory and cardiovascular system.
Assessment of gastrointestinal system.
Assessment of urinary system.
Assessment of genital system.
Assessment of extremities and musculoskeletal
system.
Assessment of endocrine system.
Assessment of heamatoboitic system.
Assessment of social system.
Assessment of psychological system.
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Methods of Assessment
1. Observing
2. Interviewing
3. Examining
Assessment Techniques
• Inspection
• Palpation
• Percussion
• Auscultation
Inspection
• Visual examination - looking
• Color, shape, size, symmetry, position and
movement
• Good lighting is very important
Palpation
• Assessment through touch
• Temperature, moisture, texture, tenderness,
masses, and edema
• May be light or deep, one hand or two
• Make sure your hands are clean and
fingernails short!
Percussion
• Short, sharp strikes to the body surface to
produce palpable vibrations and sounds
• Maybe direct (one hand) or indirect (two
hands)
• Can detect size, shape, density and location of
structures
Auscultation
• Listening to the sounds in the body (usually
with a stethoscope)
• Used to listen to lung sounds, heart sounds
and abdominal sounds
• Keep your stethoscope clean!
Physical Assesment
• Head-to-toe Assessment
• Primary
• Secondary
That-clauses
Verb + that-clause
Verbs commonly followed by that include
reporting verbs (say, tell, admit, etc.) and
mental process verbs (believe, think, know,
hope, etc.)
Examples
• They said that four million workers stayed at
home to protest against the tax.
• The survey indicated that 28 per cent would
prefer to buy a house through a building
society than through a bank.
• He knew that something bad had happened.
• Do you think that they forgot to pay or that
they stole it?
Adjective + that-clause
We use be + adjective + that-clause to express
opinions and feelings. Some adjectives
commonly used in this way are sure, certain,
right, important, afraid, pleased, sorry,
surprised, worried.
Examples
• It’s important (that) we look at the problem in
more detail.
• I’m sure (that) you’ll know a lot of people
there.
• They were afraid (that) we were going to be
late.
Noun + that-clause
We use a noun + that-clause to express opinions
and feelings, often about certainty and
possibility. We also use that with reporting
nouns. Some nouns commonly used in this way
are belief, fact, hope, idea, possibility,
suggestion, statement, claim, comment,
argument
Examples
• He is also having intensive treatment in
the hope that he will be able to train on
Friday.
• Dutch police are investigating
the possibility that a bomb was planted on
the jet.