Subjective - Answers what the patient tells you
Objective - Answers what nurse observes
Nursing Process - Answers assessment, diagnosis, outcome identification, planning,
implementation, evaluation
Interview - Answers Build rapport, Gather info, avoid judgement
Health History - Answers a collection of subjective information that provides information about
the patient's health status
PQRSTU - Answers *P*rovocative or palliative, *Q*uality or quantity, *R*egion or radiation,
*S*everity scale, *T*iming, and *U*nderstanding the patient's perception of the problem.
General Survey - Answers study of the whole person, covering the general health state and any
obvious physical characteristics
Physical appearance - Answers age, sex, level of consciousness, skin color, facial features,
overall appearance
Body structure - Answers stature, nutrition, symmetry, posture, position, body build, contour
Mobility - Answers gait, range of motion
Behavior - Answers facial expression, mood and affect, speech, dress, personal hygiene
BMI underweight - Answers <18.5
BMI normal - Answers 18.5-24.9
BMI overweight - Answers 25-29.9
BMI obese - Answers over 30
Physical exam - Answers Obtain height, weight, frame size, BMI, waist circumference
Physical Assessment Techniques - Answers Head to toe, front to back, left to right
Inspection, Palpation,Percussion, Auscultation
Inspection - Answers hands off, general observation of the patient as a whole, progressing to
specific body areas
Palpation - Answers an examination technique in which the examiner's hands are used to feel
the texture, size, consistency, and location of certain body parts
, Parts of Hand Used for Palpation - Answers Dorsal aspect: Best for temperature
Balls & ulnar surface of hand: Best for vibrations
Fingertips: Best for fine sensations
Percussion - Answers tapping the person's skin with short, sharp strokes to assess underlying
structures
Percussion
Tympanic sounds: - Answers Intestines
Percussion: Hyper-resonant - Answers Diseased lungs
Percussion: Resonance - Answers Healthy lung
Percussion: Dull - Answers organs
Percussion: Flat - Answers Muscle
Auscultation - Answers Listening with a stethoscope
Stethoscope diaphragm - Answers Used most often for high pitched sounds (breath, bowel, and
normal heart sounds)
Stethoscope bell - Answers detects low-frequency sounds such (but not limited to) as heart
murmurs
dorsal recumbent position - Answers patient is lying on the back, face up, with the knees bent
Sims position - Answers lying on left side with right knee drawn up and with left arm drawn
behind, parallel to the back
Prone position - Answers the patient lies on the abdomen with the head turned to either side
left lateral recumbent position - Answers laying on left side, part of cardiac assessment
vital signs - Answers temperature, pulse, respirations, and blood pressure
Normal temperature - Answers 98.6 F or 37 C
Normal pulse - Answers 60-100 bpm
strength of pulse - Answers 0 = absent
1+ = thready
2+ = normal