Highlights
Assessor (Patient – George Pham): You are cooperative, alert and orientated. You are willing to provide all requested information. You like to ask general questions of the nurse related to the health assessment and like to know your observations and if they are within normal limits. You are open to discuss ways to improve your health through possible changes to your diet, exercise, daily habits, and lifestyle choices.
Introduction – nurse and patient
• Situation – reasons for assessment, allergies, and relevant personal details
• Background – health history, general health and psychosocial status
• Assessment – observations, nutrition/diet, exercise, lifestyle, health beliefs and values, and cultural/spiritual/religious practices
• Recommendation – confirm health assessment information and implications for well being, recommend changes to manage and improve health and suggest timeframes for any plans
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