HA

• Interview a purposeful conversation between the nurse and the patient.
• Health History – provides a comprehensive portrait of the patient’s past and present health history
• 9 Collection of Subjective Data through Interview and Health History are 1)Biographical Data, 2)Reasons for Seeking Care, 3)Present Health or History of present illness, 4)Past Health History, 5)Family Health History, 6)Current Medications, 7)Lifestyle/Functional Health Review of Systems, 8)Developmental Level, 9)Psychosocial History
• Chief Complaint is to indicate the person’s exact words.
• Chief Complaint is now replaced with “reasons for seeking care”
• Chief Complaint is a brief spontaneous statement in the patient’s own words that described the reason for the visit
• Signs – an abnormality that can be detected on Physical Examination or laboratory studies
• Symptoms – a subjective sensation that the person feels from the disorder
• Well Person is a short statement about the general state of health.
• Ill Person is a chronological record of the reason for seeking care, from the time the symptom first started until now.
• In Past Health History is where Past health events may have residual effects on the current state of health
• Genogram or Pedigree is the most fruitful way to complete family history
• Genogram or Pedigree is a pictorial display of a person's family relationships and medical history
• The order of examination is head-to-toe (cephalocaudal)
• Psychosocial development refers to the development of personality.
• Physical Examination is an evaluation of your overall health
• Physical Examination is a routine test performed to check your overall health
• Physical Examination helps to determine the general status of your health.
• 5 types of Positioning are: 1) Sitting, 2) Supine [Horizontal Recumbent], 3)Semi-Fowlers, 4) Sims Position, 5) Dorsal Recumbent
• Sitting Position is seated position, back unsupported and legs hanging freely
• Supine (Horizontal Recumbent) Position is a back-lying position with extended legs, with or without pillow under the head
• Semi-Fowler's Position is a back-lying with the head of the bed elevated approximately 30-45degrees
• Sims Position is a side lying position with lowermost arm behind the body, uppermost leg flexed at hip, and knee, upper arm flexed at shoulder and elbow
• Dorsal Recumbent is back-lying position with knees flexed ad hips externally rotated; small pillow under the head; soles of feet on the surface
• 4 Techniques of Physical Examination are Inspection or Visual Examination, Palpation, Percussion, and Auscultation.
• Inspection or Visual Examination technique is where Nurses inspect with the use of the naked eye with sufficient lighting for better visualization
• Inspection or Visual examination technique is where nurse assess moisture, color texture of body surface, shape, position, size, color and symmetry of the body.
• Palpation is the examination of the body using the sense of touch.
•   Palpation Technique is where the nurse' Pads of fingers are used because of its high sensitivity to tactile discrimination.
• 2 Types of Palpation are: Light Palpation and Deep Palpation.
• Light palpation, the nurse extends the dominant hand’s fingers parallel to the skin surface and presses gently while moving the hand in a circle. With light palpation, the skin is slightly depressed.
• In Deep bimanual palpation, the nurse extends the dominant hand for light palpation, then places the finger pads of the non-dominant hand on the dorsal surface of the distal interphalangeal joint of the middle 3 fingers of the dominant hand. The top hand applies pressure while the lower hand remains relaxed to perceive the tactile sensation.

   
• Percussion a method in which the body surface is struck to elicit sounds that can be heard or vibrations that can be felt
• 2 Types of Percussion are: Direct and Indirect
• Direct Percussion is the area to be percussed directly with the pads of 2, 3, or 4 fingers
• Indirect Percussion is the striking of an object held against the body area to be examined.
• Pleximeter – the middle finger of the dominant hand that is placed firmly on the client’s skin.
• Plexor – the middle finger of the non-dominant hand or a percussion hammer used to strike the pleximeter.
• 5 types of Sounds Elicited by Percussion: a) Flatness; b) Dullness; c) Resonance; d)Hyperresonance; e) Tympany.
• Flatness (percussion) - Heard over solid tissue like muscle or bone.