(3) Family health history. This enhances your understanding of the
environment in which the patient lives. Obtaining this information identifies genetic
problems, communicable diseases, environmental problems, and interpersonal
relationships. Specific inquiry should be made regarding the general state of health of
parents, grandparents, siblings, spouse, and children. Record if the patient is adopted and
b. Vital Signs. The patient's vital signs are part of the objective data that helps to
better define the patient's condition and helps you in planning care. The following vital
signs may be taken at the time the patient's height and weight are obtained.
(1) Blood pressure. Blood pressure may be taken in both arms. Record
whether the patient was lying, sitting, or standing at the time the reading was obtained.
(2) Temperature. Record the temperature and whether it is an oral, axillary, or
Pulse. Peripheral pulses are graded on a scale of 0-4 by the following
0 = absent, without a pulse.
+1 = diminished, barely palpable.
+2 = average, slightly weak, but palpable.
+3 = full and brisk, easily palpable.
+4 = bounding pulse, sometimes visible.
c. Head, Eyes, Ears, Nose, and Throat. Assessment of the head begins with a
general inspection. Continue the assessment by examining the eyes, ears, nose, and
throat. Knowledge of the anatomy of the skull (figure 6-3) is helpful in localizing and
(1) Observe the general size of the head. Inspect the skull for shape and
symmetry. Note any deformities. Become familiar with the irregularities in a normal skull,
such as those near the suture lines between the parietal and occipital bones. Part the hair
in several places and inspect the scalp for scaliness, lumps, or other lesions. Note the
quantity, distribution, pattern of loss if any, and texture of the hair. Observe the patient's
facial expression and contours for asymmetry, involuntary movements, edema, and
masses. Note the color, pigmentation, texture, and any lesions of the skin.