I. Review of the Nursing ProcessII. Health History Guidelines

A. Interview1. Purpose2. Structure3. Guidelines of an effective interview

III. Health History A. Personal profile

1. Biographical Data2. Chief complaint of present illness

a. Usual health statusb. Chronological storyc. Impact on functioningd. Medications

3. Past health history4. Current medications5. Personal habits & patterns of living (ADL)6. Psychosocial History

a. Mental Status AssessmentChildren and Adolescent

Adults B. Functional Assessment

1. Adults2. Physical activities of daily living (PADC)3. Instrumental activities of daily living (IADL)

C. Functional Assessment Tests1. Newborns – Apgar scoring system2. Infants & children – MMDST3. Adults

a. Katz Index of Independence in ADLb. Barthel index

D. Review of Systems (Symptoms)E. Assessment in pregnancy (e.g. LMP, EDC)F. Pediatric Additions to Health History (e.g. head circumference, weight,

height, immunization)G. Geriatric Additions to the Health History (e.g. immunization, current

prescription medications, over the counter medications, ADL, social support, etc.)

IV. Physical ExaminationA. Preparation guidelinesB. PE guidelinesC. Techniques in Physical assessment

1. Inspection2. Auscultation3. Percussion4. Palpation

D. Continuing Assessment1. Pain2. Fever

E. Pediatric Adaptation1. General guidelines2. Specific age groups

F. Geriatric adaptations1. General guidelines2. Modifications

G. Cultural considerations 1. Sequence of PE (adult/pedia/geriatric adaptations)

a. Overviewb. Integumentc. Headd. Necke. Backf. Anterior Trunkg. Abdomenh. Musculoskeletal systemi. Neurologic systemj. Genitourinary system

H. Clinical alert I. Documentation of findings J. Patient & Family Education & Home Health Teaching

V. Diagnostic Tests (routine laboratory exams)VI. Appropriate Nursing Diagnosis

Chief Complaint

Present Problem

a. Usual health statusb. Chronological storyc. Impact on functioningd. Medications

Past Medical HistoryFamily HistoryPersonal & Social HistoryReview of Systems or Functional Patterns