The contents of health assessment include health assessment methods, common symptom assessment, physical assessment, laboratory and instrument examination, health information, psychological and social assessment, nursing medical record writing, etc. Health assessment is a process of collecting the health data of the assessed object in a planned way, and then judging the health status of the patient according to the data content.
Health assessment methods mainly include medical history, auxiliary examination and physical assessment. Common symptom assessment is a comprehensive assessment of common clinical symptoms such as fever and headache. Physical assessment is an examination of the patient's whole body or whole body system, and it is an objective data generated through organized and systematic collection. Laboratory and instrument inspection is to do relevant necessary instrument or laboratory inspection according to the patient's condition.
Health information mainly includes physical health, social health and mental health. Psychosocial assessment mainly evaluates the psychological activities, stressors and coping styles, psychological characteristics and social roles of the assessed. The writing contents of nursing medical records mainly include patient data, nursing objectives, nursing diagnosis, nursing plan and nursing effect evaluation.
General steps of health assessment:
1, subjective inquiry.
First of all, we should understand the main problems that the parties ask for help to solve, and then ask the parties about their medical history, diet history, living habits, living environment, dietary nutrition status, eating habits and hobbies, meal times and distribution ratio, cooking methods, etc.
2. objective inspection.
Check the health status of the subject, such as general body, temperature, pulse, respiration and blood pressure, as well as routine blood tests; Check the body nutrition of the subject, such as measuring height, weight, waist-hip ratio, etc. It is necessary and possible to carry out relevant laboratory tests, such as clinical biochemical tests, liver function tests, ECG, ultrasound and other equipment tests.
3. Health assessment.
According to the results of subjective inquiry and objective examination, evaluate the health status of consultants and the current health risk degree of consultants; According to the results of physical and nutritional examination, the results of dietary survey were evaluated according to the recommended daily dietary nutrient supply standard, and the current nutritional status and food structure of the clients were evaluated.