Health History Components
What are the primary components of a health history?
What is chief complaint, history of present illness, past medical history, family history, social history and review of systems?
What are the four primary assessment techniques used in physical examination?
What are inspection, palpation, percussion, and auscultation?
This is the normal resting heart rate for an adult
What is 60-100 bpm?
A patient's lungs should sound clear upon auscultation. What might wheezing indicate?
What is airway narrowing?
As seen in asthma/bronchoconstriction
This type of documentation uses direct quotes from the patient with recording symptoms
What is subjective data documentation?
This section of the health history assesses the patients daily habits, such as diet, exercise, and substance use
What is social history?
This assessment technique involves listening to body sounds, usually with a stethoscope
What is auscultation?
This is considered the most accurate body temperature, or the core body temp, but is contraindicated in infants
What is a rectal temperature?
A capillary refill time greater than this many seconds may indicate poor circulation
What is greater than 3 seconds?
This type of documentation is taken from what the nurse observes
What is objective data documentation?
This part of the health history involves a systemic review of body systems to identify any symptoms the patient may be experiencing
What is the review of systems (ROS)?
In what order should a nurse perform an abdominal assessment?
What is inspection, auscultation, and palpation? (Percussion is done by APRNs & MDs)
What are temperature, pulse, respiration, blood pressure, oxygen saturation, and pain?
This skin color change is a late sign of hypoxia
What is cyanosis?
These types of questions should be used when completing a health history
What are open-ended?
The primary reason a patient is seeking care is called this
What is chief complaint?
What is the 5th intercostal space at the mid-clavicular line?
A drop in blood pressure when going from lying to standing is called this
What is orthostatic hypotension?
Poor circulation or anemia can cause pale skin, also referred to as this
What is pallor?
Information for young children should come from what source?
What is the parents and observation?
This part of the stethoscope is best used to hear low-pitched sounds
What is the bell?
This can cause a falsely high blood pressure reading
What is a cuff that is too small?
Crackles in the lungs typically indicate this
What is fluid accumulation?