Patient assessment
Patient Assessment
Patient assessment (pronunciation: /ˈpeɪʃ(ə)nt əˈsɛsm(ə)nt/) is a critical component of healthcare, involving the systematic collection and evaluation of patient information to assist in understanding the patient's health problems and guide in the development of a plan of care.
Etymology
The term "patient assessment" is derived from the Latin word "patientem" meaning "one who suffers", and the English word "assessment" which originates from the Latin word "assessus" meaning "a sitting by".
Definition
Patient assessment is a process by which healthcare professionals gather information about a patient's physical, psychological, sociological, and spiritual status. This information is used to identify the patient's health needs and to plan individualized care for the patient.
Components of Patient Assessment
Patient assessment typically involves several components:
- Medical History: This includes the patient's past and present health status, family history, and lifestyle factors that may impact health.
- Physical Examination: This involves a systematic examination of the patient's body to detect signs of disease or abnormality.
- Vital Signs: These are measurements of the body's basic functions, such as heart rate, blood pressure, temperature, and respiratory rate.
- Laboratory Tests: These are tests performed on samples of blood, urine, or other body fluids or tissues to help diagnose disease or monitor the patient's health status.
- Diagnostic Imaging: This includes techniques such as X-rays, CT scans, and MRI scans that provide images of the inside of the body to help diagnose disease or injury.
Related Terms
- Triage: This is the process of determining the priority of patients' treatments based on the severity of their condition.
- Clinical Judgment: This is the interpretation and integration of data gathered during the patient assessment to make health care decisions.
- Patient-Centered Care: This is an approach to healthcare that involves treating the patient as an active participant in their own care and making decisions that respect the patient's wants, needs, and preferences.
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