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3.
Past Health History = the past health problems,
treatments, & outcomes.
A. Surgical history..type & date of surgery.
4 Methods (Techniques) of Physical Assessment
B. Medical Illnesses
4. Family History=
5. Allergies =
6. Current Meds
7. Prosthesis= Pacemaker, Hearing Aid, Dentures,
False Eye, False Limb
8. ADLS @ home.hygiene, bladder & bowel
elimination, hygiene, activity level, diet habits.
9. Health Practices
10. Lifestyle Habits
2.
Determine if
use
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Place
Time/date
Pupillary Reaction
1. Consensual Response = both pupils respond to light
(when shining light in 1 eye)
2. Accommodation = pupils constrict with near
objects
pupils dilate with
far objects
2.
Appearance of Drainage
Serous = clear
= bloody
= blood + serous
Mucoid = Mucous
Purulent = Contains Pus
Ears:
Functional Ability:
How is his hearing in each ear? any use of hearing
aids??
Appearance of the Ear:
Any ear pain?
IV. Integumentary Assessment
Skin Turgor = the elasticity of the skin ..Pinch the skin &
see how quickly it returns.
1.
immediate return = good hydration
2.
(slow) return = dehydration
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Lub
Dub
V. Respiratory System
Respiratory Rate & Effort?
Lung Sounds
1. Normal Lung Sounds
area of the lung, type of sound, length of sound
Insp.
Expir.
a. Tracheal
_____ _____
b. Bronchial
__ _______
c. Bronchovesicular _____ _____
*d. Vesicular
________ __
* Listen over the anterior and posterior chest of the
patient.
*For most of the chest area, you will hear Vesicular
sounds
(long inspirations---short
expirations)
* Document if lung sounds are clear anteriorly,
posteriorly, and bilaterally
2. Abnormal Lung Sounds = Adventitious
Sounds
S1*
S2
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the
if bladder is palpable
IX. MUSCULOSKELETAL SYSTEM
Assessment Lecture
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