Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.1

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4 History and Physical (H&P) Date Demographic data Source of referral Chief complaint(s) History of present illness Past history

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.5 History and Physical (H&P) Current health status Family history of illness Psychosocial history Review of all systems Information is called baseline

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.6 Variances from Normal Discriminate normal from abnormal Observation skills Use of questions Note changes in condition Need strong assessment skills Report variances to supervisor

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.7 General Survey Look at patient as whole Overall impression is valuable information Determines where to focus if time is limited What to look for in a general survey

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.8 Psychosocial Assessment Part of the general survey Emotional status Mental status Appearance

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.9 Physical Assessment Skills Inspection Auscultation Palpation Percussion

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.10 Assess Systems Musculoskeletal Integumentary Circulatory Respiratory Digestive Urinary

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.11 Assess Systems Eyes Ears Nervous Endocrine Female reproductive Male reproductive

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.12 Pain Assessment Subjective information Use pain assessment scale Scale is 0-10, 0 is no pain, 10 is worst imaginable Compare levels before and after pain medications Note nonverbal cues

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.13 ADL Assessment Activities of daily living (ADL) Actions done on a regular basis to meet physical needs Inability to perform ADLs –Assistance needed as long as unable to do so

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.14 Vital Signs (VS) Temperature Pulse Respiratory Blood pressure

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.15 Temperature Normal range essential to homeostasis Afebrile and febrile Intermittent fever Continuous fever Night sweats

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.16 Thermometer Routes Oral Axillary Rectal Aural

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.17 Pulse Pulse points Regular rhythm Irregular rhythm Regular irregular rhythm Irregular irregular rhythm

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.18 Pulse Apical pulse Stethoscope Bradycardia Tachycardia Pulse deficit Apical-radial pulse deficit

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.19 Respiration Process of moving air through lungs Inhalation (inspiration) Exhalation (expiration) Eupnea Tachypnea Bradypnea

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.20 Respiration Make sure patient is unaware respirations are being counted Rate Rhythm –Apnea –Cheyne-Stokes Respiratory effort

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.21 Blood Pressure (BP) Systolic Diastolic Hypotension Hypertension Sphygmomanometer Orthostatic (postural) hypotension

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED.22 Height and Weight Height usually stable after adulthood, except with osteoporosis Many factors affect weight Standing balance scale Chair and wheelchair scales Mechanical lift scales Bed scales