El Camino College
Associate Degree
Nursing Program
Nursing 155
Health Assessment
1.0 unit
Fall 2007/SPRING 2008
PRINTED EXCLUSIVELY FOR THE EL CAMINO COLLEGE BOOKSTORE
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N 155 HEALTH ASSESSMENT
N 155 COURSE DESCRIPTION
Students will develop and utilize health assessment skills necessary to care for clients. The focus
will be on describing normal findings and common abnormalities observed in physical
assessments of clients. Students will perform physical assessments, explain the pathophysiology
of common abnormalities, and document assessment findings.
N 155 ENTRY COMPETENCIES
Students should enter N155 with knowledge of the normal pathophysiology of cardiac,
respiratory, musculoskeletal, and peripheral vascular systems. Students should be familiar with
the physical assessment and physical assessment techniques taught in N150.
N 155 STUDENT LEARNING OUTCOMES
At the end of N155 the student will be able to complete a physical assessment of a client
identifying normal and common abnormal findings. The student will be able to document their
findings in a concise and accurate format.
N 155 COURSE OBJECTIVES
1. Gather data for a health history from an adult client.
2. Perform a physical assessment on an adult client incorporating the cardiac, respiratory,
peripheral vascular, abdominal, musculoskeletal, lymphatic, head, eyes, ears, nose, and
throat (HEENT), and neurological systems.
3. Identify normal body landmarks that correspond to underlying structures on the anterior
and posterior chest wall of a client.
4. Identify common abnormal assessment findings.
5. Compare and contrast the pathophysiology of normal and abnormal assessment findings.
6. Evaluate the impact of abnormal assessment findings on a client.
7. Document assessment findings utilizing a problem-based format.
8. Formulate a priority nursing diagnosis based upon assessment findings.
9. Complete a comprehensive health history (in the clinical setting).
N 155 UNIT OBJECTIVES:
At the end of each Module the student will:
Module One
1. Explain the purpose and components of the health history.
2. Describe effective and ineffective interviewing techniques.
3. Gather appropriate data for each health history component: biographic data, health and
illness patterns, health promotion patterns, role and relationship patterns, and a summary of
health history data.
4. Describe modifications needed to accommodate the client’s structural variables and basic
needs.
5. Document a health history utilizing AIE format.
6. Identify the steps in the nursing process and how they are used in collecting data for a
history and physical.
7. Explain how the subjective and objective data gathered during assessment relate to the
nursing process.
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8. Identify methods of collecting and organizing nursing assessment data: interviewing and
observation.
9. Identify the steps of the Mini Mental State Exam
Module II
1. Discuss the purpose and components of the physical assessment.
2. Describe the equipment required to perform the physical assessment and demonstrate its
use.
3. Identify the purpose of the following physical exam techniques: inspection, auscultation,
palpation, and percussion.
4. Demonstrate the techniques of inspection, auscultation, palpation, and percussion.
5. Describe how to perform a general survey on an adult client.
6. Utilize an adult simulator to perform a health assessment.
7. Identify the normal anatomy and physiology of the Integumentary system.
Module III
1. Identify the normal anatomy and physiology of the head, eye, ears, nose and throat
(HEENT).
2. Identify common abnormal findings (TMJ).
3. Document normal and abnormal findings of the HEENT exam using appropriate
terminology.
Module IV
1. Identify the anatomic structures and physiologic functions of the respiratory system.
2. Describe the mechanics of respiration.
3. Demonstrate how to inspect, auscultate, palpate, and percuss respiratory system structures.
4. Describe the normal findings of the respiratory system detected by inspection,
auscultation, palpation, and percussion.
5. Describe the most common abnormal findings of the respiratory system (rales, rhonchi,
wheezes, nasal flaring, clubbing, position for breathing, pursed-lip breathing, use of
accessory muscles, sternal retractions) detected by inspection, auscultation, palpation, and
percussion.
6. Document normal and abnormal findings of the respiratory system using appropriate
terminology.
Module V
1. Identify the anatomic structures and physiologic function of the heart (chambers and
valves).
2. Trace the blood flow through the pulmonary and coronary and systemic circulation.
3. Explain the events of the cardiac cycle (systole and diastole).
4. Differentiate between normal and abnormal findings of the cardiovascular system during
inspection and auscultation (lifts, heaves, pulsations, S1, S2, Split S2
5. Demonstrate auscultation of the aortic, pulmonic, tricuspid and mitral areas and describe
heart sounds normally auscultated at each site.
6. Describe common abnormal findings on auscultation of the heart (murmurs)
7. Document normal and abnormal findings of the CV system using appropriate terminology.
8. Identify the anatomic location of all peripheral pulses.
9. Review rate, rhythm, and strength of pulses.
10. Assess for jugular venous distention (JVD).
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11. Describe common abnormal findings of the peripheral vascular system (bruits and JVD)
detected by inspection, auscultation and palpation.
Module VI
1. Demonstrate how to perform an abdominal assessment on an adult client.
2. Identify and locate (by inspection, auscultation, palpation and percussion) the organs of
the gastrointestinal system (liver).
3. Differentiate between normal and abnormal findings detected on physical assessment of
the GI system (contour, pulsations, Borborygmi, ascites, rebound tenderness, guarding,
hypo/hyperactive sounds, and solid mass).
4. Document normal and abnormal findings of the GI systems using appropriate
terminology.
5. Identify normal breast tissue.
6. Perform a breast examination on a simulator
7. Describe common abnormal findings (orange peel, dimpling) on inspection and palpation
of breast tissue.
8. Describe Testicular Self Exam
Module VII
1. Describe the normal anatomy and physiology of the musculoskeletal system.
2. Identify developmental musculoskeletal system variations (scoliosis, lordosis, kyphosis,
and TMJ).
3. Explain overall body symmetry, gait, posture, and muscle and joint functions.
4. Describe systematic palpation of muscles, bones, joints, ROM, and muscle strength.
5. Document normal and abnormal findings of the musculoskeletal system using appropriate
terminology.
6. Identify the major components of the central nervous system (CNS).
7. Identify the function and assess the 12 cranial nerves.
8. Explain the difference between a neurologic screening test, a complete neurologic
assessment, and a neuro check.
9. Describe how to assess a client’s level of consciousness.
10. Compare and rate deep tendon reflexes (DTR’s) of the biceps, triceps, brachioradialis,
patellar and Achilles.
11. Document common findings on inspection, palpation, percussion and auscultation of the
Musculoskeletal and Nervous Systems using appropriate terminology.
N 155 UNIT HOURS:
This is a one unit nursing course, consisting of lecture and lab.
N 155 PREREQUISITES:
Successful completion of N150, N151, and N152.
N 155 COURSE PLACEMENT:
This course is offered during the second eight weeks of the second semester of the nursing
program.
N 155 REQUIRED TEXTS/EQUIPMENT
Jarvis, C. (2004). Physical examination and health assessment (4th ed.).
Philadelphia: W.B. Saunders Co.
A dual head or single head (cardiac) stethoscope is required for lab and pen light.
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N 155 RECOMMENDED TEXTS
Any pocket edition for Physical Assessment is acceptable.
N 155 METHODS OF INSTRUCTION:
Case Studies
Lectures and demonstrations of a sequenced basic physical exam and a cognitive status exam
Discussion of typical findings in a basic adult assessment
Group projects focused on use of assessment skills
Handouts related to various aspects of course content
Hands on physical examination practice
N 155 LEARNING ACTIVITIES
Reading (Reading list will be provided).
Assigned or recommended content in texts and references related to normal and abnormal findings
in basic physical assessment of the adult.
Documentation of history and physical findings on a sample client record
Demonstration of a timed, observed comprehensive basic physical examination
Observe, interpret and analyze client behavior
Demonstration of use of clinical assessment skills
Practice skills in the lab on student colleagues.
N 155 FACULTY RESPONSIBILITIES:
Faculty will be prepared and present to assist students in the learning lab.
Faculty will present weekly lectures. Faculty will be available to students during office hours.
N 155 STUDENT RESPONSIBILITIES:
Students will be responsible for arriving to lecture and lab on time, having completed reading
assignments. Students will be responsible for reviewing previously learned material for class.
Students will provide their own stethoscopes, penlight and wrist watch with second hand.
The student is responsible for demonstrating all behavioral objectives of the course. Clinical
evaluation is based on demonstrated ability to achieve all course objectives by the last day of
classes. Course expectations include attendance and experiential learning.
N 155 STUDENT-FACULTY COMMUNICATION:
Faculty office hours will be posted on faculty offices. Lab faculty should provide their availability
to students.
For the didactic component of the course, students should communicate with the lecturer. For the
lab component of the course, students should communicate with the lab instructor(s).
*All students and faculty have El Camino College e-mail addresses which will be utilized
throughout this course. Students are required to check their El Camino College email address
routinely in that course information and updates will be sent via email periodically throughout the
semester. Students are responsible for all information sent to them via their El Camino account.
N 155 ATTENDANCE POLICY:
Course expectations include attendance and experiential learning. Students must successfully pass
the final practical examination to complete the course.
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N 155 GRADING POLICY:
The standard nursing criteria will be utilized in the calculation of all grades. The minimum grade
points are as follows
92-100% A
90-91% A88-89% B+
83-87% B
81-82% B79-80% C+
77-78% C
75-76% C73-74% D+
65-72% D
63-64% D62% or less F
N 155 METHODS OF EVALUATION:
Quizzes
Four short 10 point quizzes will be given at the beginning of specified labs. The content of each
quiz will relate to the readings assigned for that day. Students who arrive late will not be able to
make up missed quizzes. Each quiz will be worth 10 points (10% of grade).
Lab activity documentation:
Complete and accurate documentation of assessment findings completed during clinical labs.
There will be a total of 8 (eight) documentation assignments each worth 5 points for a total of 40
points (40% of grade).
Final Practicum (Pass/Fail): This consists of performing a head to toe exam within 15 minutes.
Students must pass this in order to pass the class.
Grading:
Quizzes 4
Health History
Weekly lab documentation
Total
40%
20%
40%
100%
N155 WRITTEN HOMEWORK: HEALTH HISTORY
Students are required to complete a health history on an adult client in their clinical setting (see
paper format example on the course website). You will be given a Health History form for this
assignment by one of the course lecturers. If you are not in a clinical setting during this semester,
please notify your instructor.
Grading for the Health History:
Subjective data gathered
Identify 3 relationships between structural variables and basic needs
based on subjective data gathered with rationale and references
Identify 1 Actual and 1 ‘Risk for’ NANDA approved Nursing Diagnosis
(must be written properly)
APA Format/Grammar (see below)
Total
20 Points
10 Points
6 Points
2 Points
2 Points
20 Points
NOTE: You must follow APA guidelines when writing this paper. This includes format,
spelling, and grammar written at a college level. If you do not follow these guidelines and/or have
an unacceptable number of grammatical/spelling errors, you will receive an automatic 50% (10
points) on this assignment. NO second chance will be granted after the due date.
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Final Practicum
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N155 Health Assessment
Outline Lecture 1
Kim Baily RN, MSN, PhD
Health Assessment
o Purpose
 Assessment
 Nursing Assessment
Interviewing
o What is an interview?
Factors affecting the interview
o Internal factors
 Liking others
 Empathy
 Active Listening
o External Factors
 Privacy
 Interruptions
 Physical environment
 Dress
 Note taking
o Stages of the Interview
 Orientation
 Introductions
 Purpose of interview
 Length of interview
 Developing therapeutic relationship
 Working Phase
 Termination
 Working Phase
 Gathering data
 Open-ended questions
 Close ended questions
 Therapeutic Communication Techniques
 Facilitation
 Paraphrasing
 Restating
 Reflections
 Focusing
 Clarifying
 Silence
 Confrontation
 Summarizations
 One question at a time
 Ten Traps of Interviewing
 False reassurance
 Giving unwanted advice
 Using authority
 Using avoidance language
 Distance
 Using medical jargon
 Using leading or biased questions
 Talking too much!
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 Interrupting
 Asking “why”
 Check your non/verbal body language
 Yawning
 Body turned away
 Facial expression
 Lack of eye contact
 Gesticulations
 Touching
o Termination of Interview
 Summarize important findings
 Check with client if there is anything else they would like to discuss
 Explain what the next step will be
 Provide information
Cross Cultural Communication
o Etiquette
o Proxemics
 Intimate space – within 6 inches
 Personal space – 6 inches to 4 feet
 Social space – 4 to 12 feet
 Public space – more than 12 feet
 Comfort zone
The Complete Health History
o Biographical data
o Reason for seeking care (Was called “Chief Complaint” but this has negative connotation)
o Present health or history of present illness
o Past history
o Family history
o Review of systems
o Functional assessment or activities of daily living
Terminology Review
o Symptom – Subjective sensation
o Sign – Objective observations
Sources of Data
o Primary
o Secondary
Biographical Data
Reason for Seeking Care
o Want the client to describe their problem in their own words
o Do not interpret or rephrase complaint
o Do not use “Chief Complaint”
Present Health or History of Present Illness
o Chronological record of why pt seeking care
o Characteristics of symptom:
 Location
 Character or quality
 Quantity or severity
 Timing
 Setting
 Aggravating or relieving factors
 Associated factors
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Patient’s perception
o Analysis of Symptoms
o PQRST Mnemonic
o P: Provocative or palliative
o Q: Quality or quantity
o R: Region or radiation
o S: Severity scale
o T: Timing
o U: Understand patient’s perception
Past Health
o List of past problems,
o Childhood illness
o Chronic illness – dm 1, congenital heart dx,
o Accidents and injuries
o Hospitalizations and Operations:
o Obstetric history
o Immunizations
o Last examination date
o Allergies
o Current medications
Family History
o Genogram
Review of Systems (ROS)
o Done to ensure no significant data was overlooked
o Also asks about health promotion practices
o Series of “yes” or “no” questions
o Begins with general health (weight loss, fatigue, weakness, fever, chills present weight)
o Remember, if your client has an acute problem, every other body system will be affected
o If any positive findings from ROS, always do an analysis of the symptom (PQRSTU) on that
finding
Functional Assessment
o ADLs and self care ability;
o Activity/exercise
o Sleep/rest
o Nutrition/elimination
o Interpersonal relationships/resources
o Coping and stress management
o Personal habits
 Alcohol
 Street drugs
o Environment/hazards
o Occupational health
Perception of Health
o How do you define health?
o How do you view your situation now?
o What do you think will happen in the future?
o What are your health goals?
o Self-esteem, self-concept
o What are your concerns/goals?
o What do you expect from your health care providers?
Mental Status Examination
o Examination - ABCT
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Appearance
 Posture, body movement, dress, grooming and hygiene
o Behavior
 Level of consciousness
 Alert- awake or easily aroused
 Lethargic- not fully alert, drifts off when not stimulated
 Obtunded- sleeps most times, difficult to arouse (loud noise, vigorous shaking
or pain)
 Stupor- need persistent loud noise or pain for arousal; responds to stimuli
 Coma- no response
 Acute confusional state (delirium)
 Facial expression
 Speech
 Mood and affect
o Cognition
 Orientation (Person, time, place and purpose)
 Attention span
 Recent memory
 Remote memory
 New learning—the four unrelated words test
 Judgment
o Thought processes
 Thought processes
 Thought content
 Perceptions
 Screen for suicidal thoughts
Mini Mental State Exam
o Orientation
o Registration
o Attention and calculation
o Recall
o Language
Glascow Coma Scale
o Eye opening
o Best Verbal responsiveness
o Best Motor responsiveness
Reminders - Review
o Cultural Assessment Page 48-49
o Developmental Considerations for adult and older adult in Chapter 2.
Note: All remaining lecture outlines will be found at http://www.elcamino.edu/faculty/kbaily/index.html
Outlines should be printed out each week before lecture.
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N155 WEEK 1 – LAB
1. INTERVIEW TO OBTAIN A HEALTH HISTORY (SEE HEALTH HISTORY FORM)
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Work in groups of three
o Student 1 – Interviewer
 “Interview” patient. Remember interviewing techniques, therapeutic
communication and body language”
 Analyze any symptoms using PQRSTU mnemonic
 Document interview findings on below:
 Pick one problem and write a SOAP note on this form – hand into both
documents to lab instructor
o Student 2 – Interviewee (client)
 Pretend to be a patient with a new medical condition and a chronic health
problem (do not discuss with Student 1 or 3)
o Student 3 Recorder
 Silently observe “nurse” and ‘patient”. Make notes on interview technique,
including types of questions asked and body language of both nurse and
client. You will provide constructive feedback to the “nurse” regarding
interview technique.
Each student should attempt each role and hand in Health Form and SOAP note.
DOCUMENTATION:
Summarize findings using SOAP note:
Subjective:
Objective:
Assessment:
Plan
Nursing Diagnosis
Based on the subjective data collected above, identify one applicable nursing diagnosis and/or
collaborative problems. Write a complete nursing diagnosis using the PES format. If you
need help writing a correct nursing diagnosis please ask lab faculty.
2. COMPLETE MINI-MENTAL STATE EXAM
 Work in pairs to complete Mini-Mental State Exam
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Name of Interviewer (Nurse): ________________________
Date: _______________________
EL CAMINO COLLEGE
N155 HEALTH HISTORY
Biographical Data: (Do not fill in grey areas)
Name (Initials):
Address:
Marital Status:
Occupation:
Gender: M/F
Date of Birth:
Age:
Race:
Telephone:
Contact Person:
Source of Data:
Reason for Seeking Care:
Present Health History:
Current medical conditions
Chronic medical conditions
Medications
Food allergies
Current medical treatments
Past Health History:
Chronic illnesses (circle all that apply)
Measles
Mumps
Ear infections
Throat infections
Previous Medical
conditions
Rubella
Other:
Chicken pox
Pertussis
Previous
hospitalizations/surgeries
Accidents/Injuries
Immunizations: (Circle)
Date of last exams –
Physical, dental, vision
Women
Tetanus
Poliomyelitis
Diptheria
Hepatitis B
Date last pap smear:
Pertussis
Influenza
LMP:
Mumps
Varicella
Rubella
Other:
Date last
mammogram:
13
Family History:
(Indicate age and current health. If deceased, indicate age and cause of death.)
Mother and father:
Maternal grandparents:
Paternal grandparents:
Parents’ siblings:
Client’s siblings:
Spouse and children:
Personal and Psychosocial History:
Family/Social Relationships (significant others, individuals in home, role within family, etc)
Diet/Nutrition (include appetite, typical food intake, etc):
Functional Ability (indicate ability to independently perform following self-care activities
Mental Health (anxiety, depression, irritability, stressful events, personal coping strategies):
Person Habits:
Tobacco use: ____________________
Alcohol intake: _____________________
Illicit drug use: _______________________________________________
Health Promotion
Exercise (type/frequency):
Self-examination (type/frequency):
Oral hygiene practice (frequency of brushing/flossing):
Environment (including living and work environment)
Review of Systems: (circle all symptoms that apply, and comment below). Use PQRSTU
symptom evaluation. Remember this is not a physical exam but information which the
client reports to nurse (subjective information.)
General
Symptoms:
Pain
Problems sleeping
Comments:
Integumentary Changes in
System:
skin/color/texture
Sores that do not
heal
Comments:
Head:
Headaches
Comments:
Fatigue
Weight changes
Weakness
Fever
Excessive bruising
Itching
Skin lesions
Change in mole
Recent hair loss
Sun exposure
Head Injury
Dizziness
Fainting spells
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Eyes:
Ears:
Nose,
Nasopharynx,
Sinuses
Change in vision
Discharge
Sensitivity to
light
Correct lenses
Y/N
Comments:
Ear pain
Changes in
hearing
Comments:
Nasal discharge
Halos around
lights
Eyeglasses Y/N
Excessive
Eye pain
tearing
Difficulty
reading
Contact Lenses Y/N
Drainage
Recurrent
infections
Tinnitus
Sensitivity to
noises
Excessive wax
Hearing devices
Y/N
Frequent
nosebleeds
Postnasal drip
Sneezing
Nasal
obstruction
Snoring
Sinus pain
Change in smell
Comments:
Mouth/Oropharynx Sore throat
Sore in mouth
Bleeding gums
Change in taste
Trouble swallowing/chewing
Dental prothesis
Change in voice
Comments:
Neck
Lymph nodes
Swelling/mass
Neck pain
Stiffness
Comments:
Breasts
Respiratory
Frequent colds
SOB
Wheezing
Cough
System
Pain w breathing Cough up blood
Night sweats
Comments:
Cardiovascular
Chest pain
Palpitations
Dyspnea
Dyspnea w sleep
System
Edema
Cold extremities Discoloration
Varicose veins
Leg pain w activity
Parathesia
Comments:
GI System
Pain
Heartburn
Nausea/Vomiting Vomiting blood
Jaundice
Change appetite
Diarrhea
Constipation
Flatus
Change in bowel habits
Comments:
Urinary System
Hesitancy
Frequency
Change in stream Nocturia
Pain w urination Flank pain
Blood urine
Inc/dec urine vol
Comments:
Reproductive
Musculoskeletal
Muscle pain
Weakness
Joint Swelling
Joint pain
Stiffness
Limited ROM
Limited mobility Back pain
Comments:
Neurologic System Pain
Seizures
Fainting
Tremor
Spasms
Change in sensation, cognition, memory, coordination
Comments:
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MINI-MENTAL STATUS QUESTIONNAIRE
Max
Score
Question
ORIENTATION
1) What is the (year) (season) (date) (day) (month)?
Score
on
Date:
Score
on
Date:
Score
on
Date:
5
2) Where are we? (state) (country) (town) (hospital) (floor)
REGISTRATION
3) Repeat (immediately) 3 objects: garbage, tree, airplane.
ATTENTION / CALCULATION
4) Serial 7's or spell WORLD backwards
RECALL
5) Remember 3 objects at 2 minutes
LANGUAGE
6) Name a pencil and a watch.
5
7) Repeat "No ifs, ands, or buts."
1
8) Three stage command: “Take a paper in your right hand, fold
it in half, and put it on the floor.”
9) Written command: Please read the following
“Close your eyes”
3
5
3
2
3
2
1
10) Write a sentence.
VISUAL-SPATIAL
11) Copy a design:
1
LEVEL OF CONSCIOUSNESS (circle one)
Alert Drowsy Stupor Coma
Total Score:
30
INTERPRETATION OF TOTAL SCORE:
25-30 Normal
21-24 Mild intellectual impairment
16-20 Moderate intellectual impairment
under 15 Severe intellectual impairment
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Review of Systems: Problem Analysis.
If any problem emerges complete a more in depth assessment using the PQRSTU mnemonic:
Page 86
 P: Provocative or palliative
 Q: Quality or quantity
 R: Region or radiation
 S: Severity scale
 T: Timing
 U: Understand patient’s perception
Work in pairs
 Each student should spend a few minutes creating a health problem (don’t let other
student know what problem is).
o Either use a past health problem (nothing likely to cause embarrassment) or
invent a problem
 Take turns being interviewer
 P: Ask:
o What were you doing when the problem started?
o Does anything make it better? (meds, positioning)
o Does anything make it worse? (movement or breathing)
 Q: Ask
o Can you describe the symptom?
o What does it feel like, look like or sound like?
o To what degree does it affect your usual daily activities?
 R: Ask
o Can you point to where the problem is? Does it occur or spread anywhere else?
(Take care not to lead your client – e.g. Does it radiate to your left arm?)
o Do you have any other symptoms? Depending of CC- ask about related symptoms
– ex. If cc is CP, ask about nausea, sweating, SOB etc.
 S: Ask
o Is the symptom mild, moderate, or severe? Grade it on a scale of 0-10 (0 being no
symptom and 10 being the most severe)
o Timing: Ask
o When did the symptom start? How often does it occur? How long does it last?
 U: Ask
o What do you think these symptoms mean?
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Name of Interviewer (Nurse): ________________________
Date: _______________________
EL CAMINO COLLEGE
N155 HEALTH HISTORY
Biographical Data: (Do not fill in grey areas)
Use this form for term paper.
Name:
Address:
Marital Status:
Occupation:
Gender: M/F
Date of Birth:
Age:
Race:
Telephone:
Contact Person:
Source of Data:
Reason for Seeking Care:
Present Health History:
Current medical conditions
Chronic medical conditions
Medications
Food allergies
Current medical treatments
Past Health History:
Chronic illnesses (circle all that apply)
Measles
Mumps
Ear infections
Throat infections
Previous Medical
conditions
Rubella
Other:
Chicken pox
Pertussis
Previous
hospitalizations/surgeries
Accidents/Injuries
Immunizations: (Circle)
Date of last exams –
Physical, dental, vision
Women
Tetanus
Poliomyelitis
Diptheria
Hepatitis B
Date last pap smear:
Pertussis
Influenza
LMP:
Mumps
Varicella
Rubella
Other:
Date last
mammogram:
18
Family History:
(Indicate age and current health. If deceased, indicate age and cause of death.)
Mother and father:
Maternal grandparents:
Paternal grandparents:
Parents’ siblings:
Client’s siblings:
Spouse and children:
Personal and Psychosocial History:
Family/Social Relationships (significant others, individuals in home, role within family, etc)
Diet/Nutrition (include appetite, typical food intake, etc):
Functional Ability (indicate ability to independently perform following self-care activities
Mental Health (anxiety, depression, irritability, stressful events, personal coping strategies):
Person Habits:
Tobacco use: ____________________
Alcohol intake: _____________________
Illicit drug use: _______________________________________________
Health Promotion
Exercise (type/frequency):
Self-examination (type/frequency):
Oral hygiene practice (frequency of brushing/flossing):
Environment (including living and work environment)
Review of Systems: (circle all symptoms that apply, and comment below). Use PQRSTU
symptom evaluation. Remember this is not a physical exam but information which the
client reports to nurse (subjective information.)
General
Symptoms:
Pain
Problems sleeping
Comments:
Integumentary Changes in
System:
skin/color/texture
Sores that do not
heal
Comments:
Head:
Headaches
Comments:
Fatigue
Weight changes
Weakness
Fever
Excessive bruising
Itching
Skin lesions
Change in mole
Recent hair loss
Sun exposure
Head Injury
Dizziness
Fainting spells
19
Eyes:
Ears:
Nose,
Nasopharynx,
Sinuses
Change in vision
Discharge
Sensitivity to
light
Correct lenses
Y/N
Comments:
Ear pain
Changes in
hearing
Comments:
Nasal discharge
Halos around
lights
Eyeglasses Y/N
Excessive
Eye pain
tearing
Difficulty
reading
Contact Lenses Y/N
Drainage
Recurrent
infections
Tinnitus
Sensitivity to
noises
Excessive wax
Hearing devices
Y/N
Frequent
nosebleeds
Postnasal drip
Sneezing
Nasal
obstruction
Snoring
Sinus pain
Change in smell
Comments:
Mouth/Oropharynx Sore throat
Sore in mouth
Bleeding gums
Change in taste
Trouble swallowing/chewing
Dental prothesis
Change in voice
Comments:
Neck
Lymph nodes
Swelling/mass
Neck pain
Stiffness
Comments:
Breasts
Respiratory
Frequent colds
SOB
Wheezing
Cough
System
Pain w breathing Cough up blood
Night sweats
Comments:
Cardiovascular
Chest pain
Palpitations
Dyspnea
Dyspnea w sleep
System
Edema
Cold extremities Discoloration
Varicose veins
Leg pain w activity
Parathesia
Comments:
GI System
Pain
Heartburn
Nausea/Vomiting Vomiting blood
Jaundice
Change appetite
Diarrhea
Constipation
Flatus
Change in bowel habits
Comments:
Urinary System
Hesitancy
Frequency
Change in stream Nocturia
Pain w urination Flank pain
Blood urine
Inc/dec urine vol
Comments:
Reproductive
Musculoskeletal
Muscle pain
Weakness
Joint Swelling
Joint pain
Stiffness
Limited ROM
Limited mobility Back pain
Comments:
Neurologic System Pain
Seizures
Fainting
Tremor
Spasms
Change in sensation, cognition, memory, coordination
Comments:
20