I. Review of the Nursing Process II. Health History Guidelines A. Interview 1. Purpose 2. Structure 3. Guidelines of an effective interview III. Health History A. Personal profile 1. Chief complaint of present illness 2. Past health history 3. Current medications 4. Personal habits & patterns of living 5. Psychosocial History a. Mental Status Assessment 􀂃 Children and Adolescent 􀂃 Adults B. Functional Assessment 1. Adults 2. Physical activities of daily living (PADC) 3. Instrumental activities of daily living (IADL) C. Functional Assessment Tests 1. Newborns – Apgar scoring system 2. Infants & children – MMDST 3. Adults a. Katz Index of Independence in ADL b. 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.) III. Physical Examination A. Preparation guidelines B. PE guidelines C. Techniques in Physical assessment 1. Inspection 2. Auscultation 3. Percussion 4. Palpation D. Continuing Assessment 1. Pain 2. Fever E. Pediatric Adaptation 1. General guidelines 2. Specific age groups F. Geriatric adaptations 1. General guidelines 2. Modifications G. Cultural considerations 1. Sequence of PE (adult/pedia/geriatric adaptations) a. Overview b. Integument c. Head d. Neck e. Back f. Anterior Truck g. Abdomen h. Musculoskeletal system i. Neurologic system j. Genitourinary system H. Clinical alert I. Documentation of findings J. Patient & Family Education & Home Health Teaching K. Diagnostic Tests (routine laboratory exams) L. Appropriate Nursing Diagnosis