health history, interview, teqniques, 4 assessment, safety, documentation, skin, hair, nails Flashcards
Chief complaint
reason for seeking care
history of present illness
OLDCARTS
past medical history
past illnesses
childhood illness
surgical hx
obstetric hx
current meds
family hx
allergies
ROS
all subjective data
-review of each system to determine in patient experiencing s/s or illness within that system
subjective
what the patient says
objective
what you see
order of assessment
inspection, palpation, percussion, auscultation
except abdomin: inspect, auscultation, palpation
inspection
observing pt visually
palpation
touching of specific areasto assess
use back of hand for temp
use pads of finger for pulse and edema
use palmar surface for contour, position, pain
percussion
tapping technique with hands to determine condition of solid or air-filled body areas
flat: bone
dull: liver
Resonant: lungs
Tympany: abdomen
auscultation
using sethoscope to assess movement of air or fluid
standard precautions
prevent disease transmission during contact
gloves are standard precaution.
ophthalmoscope
visual interior eye
visual acuity tests
snellen: far
Rosenbaum: near
otoscope
ear canal and tympanic membrane