What is disease and how do you assess for it?

Disease

Definition: A departure from the state of health in which the body or mind is not functioning properly.

Assessment

1. Subjective Data

- Ask about current health status, past medical history, and family medical history.

- Inquire about symptoms such as fever, chills, fatigue, weight loss, or changes in appetite.

- Assess for pain, including location, intensity, duration, and quality.

2. Objective Data

- Vital signs: Measure temperature, pulse, respirations, and blood pressure.

- Physical examination: Inspect for signs of illness such as pallor, jaundice, rash, or edema. Auscultate the heart and lungs for any abnormalities. Palpate the abdomen for any tenderness or masses.

3. Laboratory Tests

- Complete blood count: This test can reveal anemia, infection, or other abnormalities in the blood.

- Chemistry panel: This test can measure electrolytes, liver function, kidney function, and blood sugar levels.

- Urinalysis: This test can detect abnormalities in the urine that may indicate infection, kidney disease, or diabetes.

- Imaging studies: X-rays, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans can help identify structural abnormalities or disease processes in the body.

4. Additional Assessments

- Depending on the suspected illness, additional assessments such as electrocardiogram, pulmonary function tests, or endoscopy may be necessary.

5. Functional Assessment

- Assess the individual's ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

- Identify any barriers or limitations that may interfere with the individual's ability to function independently.

6. Psychosocial Assessment

- Assess the individual's emotional well-being, coping mechanisms, and social support system.

- Identify any stressors or life changes that may contribute to the illness.