N 224 Lecture Notes - Lecture 1: Dander, Heart Sounds, Circulatory System
Document Summary
Subjective: what the pt tells you/describes: my back hurt , i do not feel well , all information in the ros is subjective, pain is always subjective. Objective: what you see, observe, palpate, etc. during the physical assessment: bp, pulse, respirations, temp, pt looks uncomfortable and walks bent over, lung sounds, heart sounds, bowel sounds, etc. Present health or history of present illness (hpi: pqrstu of symptoms, more of a narrative. Past history (ph: allergies dander, food, pollen, medications. A review of each system of the body: like gi system, cardiovascular system, etc. Generally begin at the head and move down. Most will ask about symptoms or disorders of the system + important chronic and common disorders. Does the pain travel: s severity scale 0-10, t timing, when does it occur, how long does it last, u understand the patients perception of the problem. Old carts: onset, location, duration, characteristics, aggravating factors, relieving factors, treatment (tried, severity.
