1. History & Physical 1. Info gathered determines: Level of health
Need for testing or exams
Tentative diagnosis
Preventive measures needed
Type of treatment

2. History & Physical 2. Length & detail: For primary physician
Simple history gives good idea about what’s going on
For specialist
Greater detail about past problems to indicate a pattern

3. History & Physical 3. Common components:
Chief Complaint (CC): signs and symptoms; duration of symptoms
History of present illness (HPI): symptom detail, order of occurrence & length of each
Past History (PH): prior illnesses & dates of occurrence
Operations
Hospital admissions
Serious injuries
Shot record
Allergies
# of pregnancies

4. History & Physical
Family history (FH): health status of immediate family looking for hereditary tendencies
Social & occupational history (SH): job, living environment, travel, personal habits, lifestyle
Review of systems (ROS): history of symptoms patient forgot to mention
franciscanpainandneurology.com/forms

5. Vital Signs

6. Vital Signs
Various determinations which provide information about basic condition of the patients
When the signs with in normal limits, body in homeostasis, a state of equilibrium
Abnormal vital signs are often first indication of something wrong- ACCURACY is essential

7. Vital Signs MAIN VITAL SIGNS: Temperature (T) Pulse (P)
Respiration (R)
Blood pressure (B/P)

8. TEMPERATURE
Measurement of balance between heat lost & heat produced in body
Heat Loss: perspiration, respiration, excretion
Heat production: metabolism, muscle activity

9. TEMPERATURE Factors affecting body Temperature: Eating hot food
Drinking hot or cold liquids
Time of Day
Smoking
Temperature of environment
Body metabolism

10. TEMPERATURE Parts of the body where temperature is measured
Oral Temperature:
- normal range: F (98.6 F)
- most common, convenient, comfortable method

11. TEMPERATURE - Rectal: - Normal range: 98.6-100.6F (99.6F)
- Most accurate because a core measurement

12. TEMPERATURE Axillary or groin: - Normal range:96.6-98.6 F (97.6F)
- Least accurate because external
Aural or Tympanic:
Temperature of blood flowing through tympanic membrane
Accurate-core temp

13. TERMS
Afebrile- without fever
Febrile- having fever

14. TEMPERATURE Conversion between Fahrenheit & Celsius
- To convert Fahrenheit (F) to Celsius (C):
C= (F-32) x 5/9\
To Convert Celsius (C) to Fahrenheit (F):
F= (C x 9/5) + 32

15. Practice Temperatures

16. PULSE

17. PULSE
- The wave of blood created by the heart pumping as it travels along the arteries.
- Most easily felt in arteries which lie close to the skin & can be pressed against the bone

18. PULSE Eight Locations: Temporal (temple) Carotid (neck)
Apical (apex of heart)
Brachial ( inner aspect of elbow)
Radial (wrist)
Femoral (groin)
Popliteal (behind the knee)
Pedal (Top of foot)

19. PULSE
Radial artery most common sight to take pulse

20. PULSE Pulse rate: Noted as the number of beats per minute (BPM)
-Rates vary depending of age, sex, body size

21. PULSE Normal adults rates: 60-80 BPM -men: 60-79 -women: 65-80
Children
- over 7: 72-90
1-7 :
Infants:

22. PULSE Terms associated with pulse rate: Bradycardia: under 60 BPM
Tachycardia: over 100 BPM
Arrhythmia: uneven interval between heartbeats

23. PULSE Factors increasing pulse rates:
Exercise, excitement, nervous tension
Stimulant drugs
Shock
fever

24. PULSE
Factors decrease pulse rates:
Sleep
Coma
Depressant drugs

25. Respiration Breathing rate Begins when level of CO2 increases
One inspiration & one expiration=one respiratory cycle
Do not allow patient to know rate is being counted

26. Respiration
Normal rates
Adults:
Children:
Infants:

27. Factors Affecting Respiratory Rate
Exercise
Strong emotions
Trauma
Chronic/acute lung diseases
Cardiovascular diseases

28. Abnormal Respirations
Dyspnea
Difficult or labored breathing
Apnea
Absence of respirations
Cheyne-Stokes
Periods of dyspnea followed by periods of apnea
Frequently noted in dying patients
Rales
Bubbling or noisy sounds caused by fluids or mucus in air passages
Wheezing
High-pitched musical squeak

29. Blood Pressure

30. Blood Pressure
Measurement of pressure of the blood exerted against walls of arteries
Two measures:
Systolic: heart contracts
Diastolic: heart relaxes
Written as a fraction: 120/80
Units of measure: mm Hg

31. Blood Pressure Factors increasing B/P Factors decreasing B/P
Excitement, anxiety, nervous tension
Stimulant drugs
Exercise
Eating
Factors decreasing B/P
Rest or sleep
Fasting
Depressant drugs
Excessive loss of blood

32. Blood Pressure Instrument of measure: sphygmomanometer Types:
Sphygmo-: pulse
Man: pressure
Meter: measure of
Types:
Mercury-long column of mercury
Aneroid-a round gauge
Digital

33. Blood Pressure Reading the gauge Long marks: units of 10 mm Hg
Short marks: units of 2 mm Hg

34. TIME Why is time important? Indicates: When treatment is to be done
When medication to be given
How long procedures last

35. TIME Military time Expressed in 4 digits
No colons between hours/minutes
Use 0 to complete 4-digit number
0300 rather than 300
Stated in hundreds
Zeros three hundred=3:00 AM
Twenty-two hundred hours=10:00 PM
Use 24 hour clock
AM=0100 to 1200
PM=

36. Comparison of Greenwich to Military Time
1:00 AM 0100
2:00 AM 0200
3:00 AM 0300
4:00 AM 0400
5:00 AM 0500
6:00 AM 0600
7:00 AM 0700
8:00 AM 0800
9:00 AM 0900
10:00 AM 1000
11:00 AM 1100
12:00 noon 1200
1:00 PM 1300
2:00 PM 1400
3:00 PM 1500
4:00 PM 1600
5:00 PM 1700
6:00 PM 1800
7:00 PM 1900
8:00 PM 2000
9:00 PM 2100
10:00 PM 2200
11:00 PM 2300
12:00 PM 2400

37. Convert the following to Military.24-hour time
10:43 a.m.
10:27 p.m.
11:21 a.m.
8:16 p.m.
9:32 p.m.
3:19 p.m.
9:10 a.m.
12:22 a.m.
12:22 p.m.

38. Write these 24-hour clock times in 12-hour clock times, using a. m
Write these 24-hour clock times in 12-hour clock times, using a.m. or p.m.
1213
1705
0622
1635
1942
2205
1340
1445