Collect Patient Data Patient Interview Completed on admission

Collect Patient Data Patient Interview • Completed on admission to a health care facility – In-patient facility or Outpatient facility • Prepare for the patient: – Room is neat – Supplies are available – Review the patient’s chart to anticipate patient needs 3. 01 Understand Diagnostic and Therapeutic Services 1

Collect Patient Data Patient Interview Obtain Medical History –Chief complaint –Medical history –Family history –Social history –Review of body systems 3. 01 Understand Diagnostic and Therapeutic Services 2

Collect Patient Data Patient Assessment Subjective what the patient states (symptoms) perceived to exist by the patient may not be recognizable to anyone else Mr. Helms states “my stomach hurts” “My jaw aches. ” **Remember the pain scale! 3. 01 Understand Diagnostic and Therapeutic Services 3

Collect Patient Data Patient Assessment Objective what is seen or measured (signs) • Measurable: – vital signs – weight and height – test results – Disease symptoms that can be observed by somebody other than the person who is ill i. e. cough, lacerations – Compare what is normal versus abnormal

Collect Patient Data Patient Assessment What do you see? 3. 01 Understand Diagnostic and Therapeutic Services 5

Collect Patient Data Patient Assessment See (observe) What do you see? 3. 01 Understand Diagnostic and Therapeutic Services 6

Collect Patient Data Patient Assessment SMELL What do you smell? • unusual odors – body – breath – wounds – body fluids 3. 01 Understand Diagnostic and Therapeutic Services 7

Collect Patient Data Patient Assessment TOUCH • • What do you feel? pulse warm/cold wet/dry soft/firm Palpation: use the hands to determine size, shape, location, and firmness of the body parts Percussion: tapping body parts 3. 01 Understand Diagnostic and Therapeutic Services 8

Collect Patient Data Patient Assessment HEAR • • What do you hear? body sounds speech breathing laughter/crying 1 Auscultation- listening to internal body sounds, usually with a stethoscope 3. 01 Understand Diagnostic and Therapeutic Services 2 3 4 9

Collect Patient Data Patient Assessment Using medical instruments

Collect Patient Data Patient Assessment Using medical instruments Ophthalmoscope used to examine the eyes 3. 01 Understand Diagnostic and Therapeutic Services 11

Collect Patient Data Patient Assessment Using medical instruments Otoscope used to examine the ears 3. 01 Understand Diagnostic and Therapeutic Services 12

Collect Patient Data Patient Assessment Using medical instruments Penlight used to determine pupil size/reaction 3. 01 Understand Diagnostic and Therapeutic Services 13

Collect Patient Data Patient Assessment Using medical instruments Reflex hammer used to test reflexes 3. 01 Understand Diagnostic and Therapeutic Services 14

Collect Patient Data Patient Assessment Using medical instruments Scales used to measure weight Balance-beam scale Wheelchair scale Baby scale 3. 01 Understand Diagnostic and Therapeutic Services Mechanical lift with a scale 15

Collect Patient Data Patient Assessment Using medical instruments Sphygmomanometer used to measure blood pressure 3. 01 Understand Diagnostic and Therapeutic Services 16

Collect Patient Data Patient Assessment Using medical instruments Stethoscope used to listen to internal body sounds 3. 01 Understand Diagnostic and Therapeutic Services 17

Collect Patient Data Patient Assessment Using medical instruments Thermometer used to measure heat Non-mercury glass thermometer Aural thermometer Digital thermometer 3. 01 Understand Diagnostic and Therapeutic Services Electronic thermometer 18