健康评估（Health Assessment）

卢舜飞、蓝雪芬等

目录

  • 1 course introduction
    • 1.1 study guide(English version)
    • 1.2 study guide (Chinese version)
    • 1.3 schedule
    • 1.4 materials
    • 1.5 introduction
    • 1.6 videos of history taking and physical examination
  • 2 Common symptoms
    • 2.1 collecting subjective data
    • 2.2 Mind map and English Materials
    • 2.3 fever
    • 2.4 cyanosis
    • 2.5 dyspnea
    • 2.6 cough and expectoration
    • 2.7 edema
    • 2.8 jaundice
    • 2.9 hymoptysis
    • 2.10 haematemesis
    • 2.11 pain
    • 2.12 disturbance of consciousness
  • 3 physical exmination
    • 3.1 overview of physical examination
    • 3.2 assessing general health status
    • 3.3 assessing head and neck
    • 3.4 assessing thorax and lungs
    • 3.5 assessing heart
    • 3.6 assessing abdomen
    • 3.7 assessing spine, limbs and nervous system
  • 4 laboratory examination
    • 4.1 blood, urine and feces examination
    • 4.2 liver and kidney examination
  • 5 ECG examination
    • 5.1 normal ECG
    • 5.2 abnormal ECG
  • 6 nursing diagnosis and nursing records
    • 6.1 nursing diagnosis and nursing records
assessing heart




Case study

Historyof present health ：

Patient,female, 45 years old. Chest tightness, shortness of breath for 8 years, withrepeated hemoptysis for 1 year.

Physicalexamination:

Cardiacauscultation:

Mitralvalve area: mid- and late diastolic rumbling murmurs, first heart sound hyperactivity, open heart sound，second heart sound hyperactivity in pulmonary valve.

Questions:

 1. What is the most possiblediagnosis of this client? In order to make a accurate diagnosis, what kinds ofaccessory examination should be done?

2.What are the positive signs of the patient's physical examination?

3.Pleasegive the nursing diagnoses, collaborative problems.