Health History and Physical Assessment

What are the components of a health history?

pt. interview, pt. preparation, and review of system

What do you ask during a pt. interview?

demographics, chief complaint, allergies, medication, and immunizations

What do you ask for demographic information?

work, sex, marital status, age, name, dob, etc

What is a chief complaint?

why the pt. is there

What do you ask about allergies?

type of reaction and severity (medication, environmental and food reaction)

What do you ask about medications?

what they are currently taking, over the counter, and supplements

What do you ask about immunizations?

what shots they’ve taken and when

What is apart of health history data?

past medical/surgical history, family history, social history, cultural/spiritual/religious traditions, ADLs, and cognitive/emotional status

What is past medical and surgical history?

compare medication with their history, surgical history can affect current diagnosis

What is included in family history?

immediate family’s medical diagnosis

What is apart of social history?

tobacco/nicotine use (ppd), alcohol usage, drug usage, safety concerns, sexual history (how many bodies)

Why are cultural, spiritual, or religious tradition important?

need to know to treat pt. respectfully

What are activities of daily living?

eating, bathing, eliminating, hygiene, and mobility

What is the difference between cognitive and emotional status?

cognitive ensures that they are alert and oriented, emotional status is affected by situation; this establishes a baseline

What is a review of system (ROS)

how you are feeling in every body system such as: integumentary, neuro, cardiac, respiratory, digestive, urinary

What are the types of assessment?

complete and focused

What are the assessment techniques?

inspection (sight), palpation (touch), percussion (touch and hearing), auscultation (hearing)

What is included in a general survey?

age, race/ethnicity, sex/gender identity, safety concerns, affect/mood

What is the difference between affect and mood?

outward emotion shown vs how you feel

What are some of the components that affect emotional, mental and social well-being?

affect/mood, drug use, hygiene/grooming, sensory deficits

What must you inspect when conducting the integumentary assessement?

skin, hair, temperature, lesions, elasticity

When palpating the skin what are you feeling for?

temperature, turgor (elasticity), edema (fluid swelling)

What is HEENT?

head, eyes, ears, nose, throat

What are you looking for in HEENT?

head - deformities, eyes - PERRLA, ears - drainage, nose - drainage, deformities, throat - deformities, tonsils, blood vessels, bruet, thrill

What is PERRLA?

pupil, equal, round, reactive (same bilateral), light, accommodation

What must you know when palpating in the cardiac system?

skin temperature, peripheral pulses, edema, capillary refill

What are pulse points?

where an artery hits a bone

Why is symmetry important in the cardiac system?

needed in order to make sure both sides have symmetrical circulation

What must you know for auscultating the cardiac system?

normal heart sounds (lub and dub), abnormal heart sounds (murmurs), APTM

What is the difference between lub and dub?

systole vs diastole

What could abnormal heart sounds be an indicator of?

valve issues

What does APTM stand for?

aortic, pulmonary, tricuspid, and mitral

What should you inspect in the cardiac system?

skin color, PMI

What should be inspected for a respiratory assessment?

shape/configuration, breathing patterns, abnormal assessment findings, palpation, tactile fremitus, and auscultation

What is the configuration of the lungs?

2 lobes on the right, 1 lobe on the left

What are the normal sounds associated with the respiratory system?

vesicular sounds, bronchial sounds, bronchial vesicular sounds

What are the abnormal sounds to listen for in the respiratory system?

crackles (rales), rhonchi, wheezes

How do you palpate for respiratory system?

thumbs separate 3-5cm deep during inspiration, outline shoulder blade with thumbs, asses for bulges, tenderness or abnormal mvmts. palpate for respiratory excursion

What must you inspect for a basic abdominal assessment?

four quadrants, contour, symmetry, pulsations, and umbilicus

What must you auscultate for during an abdominal assessment?

bowel sounds, normal sounds, abnormal sounds

What are the different contours of the abdomen?

flat, scaphoid, rounded, protuberant

What are bowel sounds?

peristalsis (rhythmic squeezing of food) every 2-3 seconds

What are indications of mental status?

appearance, behavior, communication, level of consciousness, orientation, sensation, motor, cerebellar function, gait, balance, coordination, pupillary response