1: History and Physical Assessment

Part 1 History and Physical Assessment



HEALTH HISTORY



Information





Past history (PH)


To elicit a profile of the individual’s previous illnesses, injuries, or operations



1. Pregnancy (maternal)









2. Labor and delivery






3. Perinatal period








4. Previous illnesses, operations, or injuries







5. Allergies




6. Current medications



7. Alternative remedies



8. Pain






9. Immunizations





10. Growth and development











11. Habits

















12. Nutrition











REVIEW OF SYSTEMS


General—Overall state of health, fatigue, recent and/or unexplained weight gain or loss (period of time for either), contributing factors (change of diet, illness, altered appetite), exercise tolerance, fevers (time of day), chills, night sweats (unrelated to climatic conditions), frequent infections, general ability to carry out activities of daily living, behavior


Integument—Pruritus, pigment or other color changes, acne, moles, birthmarks, discoloration, eruptions, rashes (location), tendency toward bruising, petechiae, excessive dryness, general texture, disorders or deformities of nails, hair growth or loss, hair color change (for adolescent, use of hair dyes or other potentially toxic substances such as hair straighteners)


Head—Headaches, dizziness, injury (specific details)


Eyes—Visual problems (ask about behaviors indicative of blurred vision, such as bumping into objects, clumsiness, sitting very close to the television, holding a book close to the face, writing with head near desk, squinting, rubbing the eyes, bending the head in an awkward position), cross-eye (strabismus), nystagmus, eye infections, edema of lids, excessive tearing, use of glasses or contact lenses, date of last optic examination


Nose—Nosebleeds (epistaxis), constant or frequent running or stuffy nose, nasal obstruction (difficulty in breathing), alteration or loss of sense of smell


Ears—Earaches, discharge, evidence of hearing loss (ask about behaviors such as need to repeat requests, loud speech, inattentive behavior), results of any previous auditory testing, pulling or rubbing ear


Mouth—Mouth breathing, gum bleeding, toothaches, toothbrushing, use of fluoride, difficulty with teething (symptoms), last visit to dentist (especially if temporary dentition is complete), response to dentist


Throat—Sore throats, difficulty in swallowing, choking (especially when chewing food—may be from poor chewing habits), hoarseness or other voice irregularities


Neck—Pain, limitation of movement, stiffness, difficulty in holding head straight (torticollis), thyroid enlargement, enlarged nodes or other masses


Chest—Breast enlargement, discharge, masses, enlarged axillary nodes (for adolescent female, ask about breast self-examination)


Respiratory—Chronic cough, frequent colds (number per year), wheezing, shortness of breath at rest or on exertion, difficulty in breathing, sputum production, infections (pneumonia, tuberculosis), date of last chest x-ray examination, and skin reaction from tuberculin testing


Cardiovascular—Cyanosis or fatigue on exertion, cold extremities, history of heart murmur or rheumatic fever, anemia, date of last blood count, blood type, recent transfusion


Gastrointestinal—nausea, vomiting (not associated with eating, may be indicative of brain tumor or increased intracranial pressure), jaundice or yellowing skin or sclera, belching, flatulence, recent change in bowel habits (blood in stools, change in color, diarrhea, and constipation)


Genitourinary—Pain on urination, frequency, hesitancy, urgency, hematuria, nocturia, polyuria, unpleasant odor to urine, force of stream, discharge, change in size of scrotum, date of last urinalysis (for adolescent, sexually transmitted disease, type of treatment; for male adolescent, ask about testicular selfexamination)


Gynecologic—Menarche, date of last menstrual period, regularity or problems with menstruation, vaginal discharge, pruritus, date and result of last Pap smear (include obstetric history as discussed under birth history when applicable); if sexually active, type of contraception


Musculoskeletal—Weakness, clumsiness, lack of coordination, unusual movements, back or joint stiffness, muscle pains or cramps, abnormal gait, deformity, fractures, serious sprains, activity level, redness, swelling, tenderness


Neurologic—Seizures, tremors, dizziness, loss of memory, general affect, fears, nightmares, speech problems, any unusual habit


Endocrine—Intolerance to weather changes, excessive thirst and urination, excessive sweating, salty taste to skin, signs of early puberty


Lymphatic—History of frequent infections, enlarged lymph nodes in any region, swelling, tenderness, red streaks



CULTURAL ASSESSMENT




1. Communication






2. Health beliefs








3. Religious practices and rituals







4. Diet practices










5. Family characteristics









6. Sources of support








SUMMARY OF PHYSICAL ASSESSMENT OF THE NEWBORN



Usual Findings




1. General measurements







2. Vital signs










3. General appearance



4. Skin









5. Head






6. Eyes









7. Ears





8. Nose






9. Mouth and throat












10. Neck




11. Chest






12. Back and rectum







13. Extremities










14. Neuromuscular system







Oct 20, 2016 | Posted by in NURSING | Comments Off on 1: History and Physical Assessment

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