Chapter 14: Principles of Assessment
Topics
● Principles of Assessment
● The Physical Examination
● Body System Examinations
● Critical Thinking and Decision Making
Principles of Assessment
The Patient History
● Patient history has two different components:
○ History of the present illness (HPI)
○ Past medical history (PMH)
History-Taking Techniques
● History is obtained by talking to the patient
● If the patient is unable to respond, gather history from:
○ Family members
○ Bystanders
○ Medications present
○ Other things you observe at the scene
● Develop a rapport with the patient
● Ask open-ended questions
● Only use closed-ended questions if you need an immediate answer
● History taking helps you obtain a picture of what is going on with the patient
● Use the mnemonic OPQURST to learn about the chief complaint and history of the
present illness/injury
○ Onset
○ Provocation
○ Quality
○ Region, radiation
○ Severity
○ Time
● Use the mnemonic SAMPLE to learn about the patient’s past medical history
○ Signs and symptoms
○ Allergies
○ Medications
○ Pertinent past history
○ Last oral intake
○ Events leading to the injury or illness
● When assessing children:
○ Preschoolers can be interviewed with simple language
○ School-age children will be able to describe what they feel and what happened
○ Include parents, teachers, and/or care providers in your interview
, The Physical Examination
Physical Examination Techniques
● Performed before, during, or after patient history
● Three primary techniques
○ Observe- Look at the patient for an overall sense of patient condition
○ Auscultate- Listen for sounds of an abnormal condition
○ Palpate- Feel an area for deformities or other abnormal findings
Pediatric Physical Exam
● Approach frightened children slowly
● Start from the least invasive parts to the most invasive
● Start with the toes or trunk and work your way toward the head
● Explain all equipment to the child before use
● Never lie to a child about something that hurts
● Provide for the patient’s privacy
Body System Examinations
Respiratory System
● The most important determinationwhen assessing the respiratory system is whether the
pain is breathing adequately
Respiratory Assessment-History
● Obtain history of existing respiratory conditions and medications taken for each
● Determine if medications have been taken as prescribed
● Determine is signs and symptoms of this episode match previous episodes
Respiratory Assessment-Physical Examination
● Mental status
● Level of respiratory distress
● Chest wall motion
● Auscultate lung sounds
● Use pulse oximetry
● Observe edema
● Fever
Cardiovascular System
● Heart
● Blood pressure
● Cardiac patient and patient with shock or with a vascular problem
Cardiovascular System-History
● Existing cardiac conditions and medications
● Signs and symptoms of epsiode
● Description of chest pain using OPQRST
Topics
● Principles of Assessment
● The Physical Examination
● Body System Examinations
● Critical Thinking and Decision Making
Principles of Assessment
The Patient History
● Patient history has two different components:
○ History of the present illness (HPI)
○ Past medical history (PMH)
History-Taking Techniques
● History is obtained by talking to the patient
● If the patient is unable to respond, gather history from:
○ Family members
○ Bystanders
○ Medications present
○ Other things you observe at the scene
● Develop a rapport with the patient
● Ask open-ended questions
● Only use closed-ended questions if you need an immediate answer
● History taking helps you obtain a picture of what is going on with the patient
● Use the mnemonic OPQURST to learn about the chief complaint and history of the
present illness/injury
○ Onset
○ Provocation
○ Quality
○ Region, radiation
○ Severity
○ Time
● Use the mnemonic SAMPLE to learn about the patient’s past medical history
○ Signs and symptoms
○ Allergies
○ Medications
○ Pertinent past history
○ Last oral intake
○ Events leading to the injury or illness
● When assessing children:
○ Preschoolers can be interviewed with simple language
○ School-age children will be able to describe what they feel and what happened
○ Include parents, teachers, and/or care providers in your interview
, The Physical Examination
Physical Examination Techniques
● Performed before, during, or after patient history
● Three primary techniques
○ Observe- Look at the patient for an overall sense of patient condition
○ Auscultate- Listen for sounds of an abnormal condition
○ Palpate- Feel an area for deformities or other abnormal findings
Pediatric Physical Exam
● Approach frightened children slowly
● Start from the least invasive parts to the most invasive
● Start with the toes or trunk and work your way toward the head
● Explain all equipment to the child before use
● Never lie to a child about something that hurts
● Provide for the patient’s privacy
Body System Examinations
Respiratory System
● The most important determinationwhen assessing the respiratory system is whether the
pain is breathing adequately
Respiratory Assessment-History
● Obtain history of existing respiratory conditions and medications taken for each
● Determine if medications have been taken as prescribed
● Determine is signs and symptoms of this episode match previous episodes
Respiratory Assessment-Physical Examination
● Mental status
● Level of respiratory distress
● Chest wall motion
● Auscultate lung sounds
● Use pulse oximetry
● Observe edema
● Fever
Cardiovascular System
● Heart
● Blood pressure
● Cardiac patient and patient with shock or with a vascular problem
Cardiovascular System-History
● Existing cardiac conditions and medications
● Signs and symptoms of epsiode
● Description of chest pain using OPQRST
