Health History & General Survey

Nursing process ADPIE

Assessment

diagnose

Plan

Implement

evuate

Soap

Subjective

Objective

Assessment

Plan

Health History Sequence BSRPPFRF( BMW, Supra, Range Rover, Present, Past, Future, Review, Functions)

Biographical data

source of history

reason for care

present health or history of illness

past medical

family history

review of system

functional assessment with adl

Biographical data NAPABBSMREO

Name

Address & phone number

Age & birthdate

birthplace

sex

martial status

ethic origin

occupation

Present health of history of illness LCQQSTSARAP

Location

Character & quality

Quantity & severity

Timing

Setting

Aggravating or reliving

Associated factors

Patient perception

PQSTU

Proactive & Palliative

Quality or quantity

Region or radiation

Severity scale 1-10

Timing or onset

Understanding patients perception of problem

Past Medical History

Chilhood illness

Accidents or injuries

Serious or chronic illness

Hospitalizations

Operations

Obstetric history

Immunizations

Last examination date

Allergies

Current medication

Review of systems head

Overall state

Skin

Hair

Head

Eyes

Ear

Nose

Ears

Sinus

Mouth throat

Neck

Review of systems chest

Breast

Axilla

Respiratory

Cardiovascular

Peripheral vascular

Gastrointestinal

Urinary system

review of systems overall

male genital

female genital

sexual health

musculoskeletal

Neurologic

Hematologic

Endocrine

CAGE

Cut

Annoyed

Guilty

Eye opener

Adolescent psychological interview HEEDADSSS

Home

Education and employment

Eating

Activity

Drugs

Sexuality

Suicide and depression

Safety

Ethical Principles

Nonmaleficence, beneficence, autonomy, justice.

Communication ISBARR

Identify

Background

Assessment

Recommendation

Read-back

Force / strength of pulse

0 absent impalpable

1 weak dimisnihed

2 normal brisk

3 increases strong

4 bounding full volume

BMI

underweight: 18.5

Healthy 18.5 top 24.9

Over weight 25 to 29.9

Obese 30 and above

Mobility

Spactity: increased muscle tone

Rigidity: resistant to any manipulation of joint

Fasciculation: continues muscle movement

Myoclonus: jerking

Tic: repeat muscle movement

Tremors: opposing muscle groups

Body posture plumb line

Outer ear

shoulder

hip

patella

ankle

Level of consciousness PTPE

Person

Time

Place

Event