Health History and Physical Assessment

1. 1 Health History and Physical Assessment Rachel S. Natividad, RN, MSN, NP

2. 2 HISTORY and PHYSICAL ASSESSMENT OBJECTIVES Discuss different methods and the sequencing used for basic physical assessment for each body system Describe the components of the complete health history Identify significant findings of a health history and physical assessment of a patient Discuss the normal assessment and common abnormal findings for each body system Successfully complete a physical assessment practicum

3. 3 Health History Physical Assessment Subjective database Obtained through interview ID strength, actual or potential health problems, support system, teaching needs, DC and referral needs Use of effective communications skills Objective database Obtained by observation and physical assessment techniques Completes the client�s health picture

4. 4 Complete Health History (Jarvis) Biographical data Reason for Seeking Care History of Present Illness Past Health Accidents and Injuries Hospitalizations and Operations Family History Review of Systems Functional Assessment ( Activities of Daily Living) Perception of Health

5. 5 Biographical Data (exercise) Name: Age: Birthplace: Gender: Marital status: Occupation:

6. 6 Complete Health History-Cont. Reason for seeking care: What brought you here today? (symptom/s & duration) History of Present Illness Arranges symptoms in chronological order from the time of onset to the present time. Includes an Analysis of the Symptom

7. 7 HPI: Analysis of the Symptom P Provokes What makes symptoms better/worse? Q Quality What does pain feel like? R Region/Radiation Where & where does pain go? S Severity On Scale of 1-10 (other scales) T Time When, How often, How long?

8. 8 Review of Systems A series of questions re: pt�s current and past health including health promotion practices Inquires about signs and symptoms as well as diseases related to each body system The review of systems is a useful method for gathering medical information in an orderly fashion. This review is a series of questions about the person's current and past medical experiences. It usually proceeds from general to specific information. A thorough record of relevant dates is important in determining relevance of past illnesses or events to the current condition. A review of systems typically follows a head-to-toe order. So as not to omit anything that pt may have forgotten to report. Or feel is not important to report. If no specific complaint about a system, do a ROS on that system as part of subjective dataThe review of systems is a useful method for gathering medical information in an orderly fashion. This review is a series of questions about the person's current and past medical experiences. It usually proceeds from general to specific information. A thorough record of relevant dates is important in determining relevance of past illnesses or events to the current condition. A review of systems typically follows a head-to-toe order. So as not to omit anything that pt may have forgotten to report. Or feel is not important to report. If no specific complaint about a system, do a ROS on that system as part of subjective data

9. 9 Document your Findings � Health History Documentation forms vary per agency Use of standardized nursing admission assessment forms Combines health history and physical assessment

10. 10 Physical assessment Validates the patient�s complaints related to health Assists in formulating nursing diagnoses and interventions Monitors current health problems Obtains baseline information for future assessments Validates the patient�s complaints related to health Assists in formulating nursing diagnoses and interventions Monitors current health problems Obtains baseline information for future assessments

11. 11 Assessment Sequencing Head � to - Toe Assessment Body Systems Assessment Head to toe Begins at head and progresses down to the toes Most comprehensive Used to obtain baseline information to identify changes in patient status Systems Focuses on one system at a time Cardiac: heart sounds, pulses, capillary refill, B/P Respiratory: breath sounds, rate and depth, skin color Head to toe fashion � organized - everything assessed from head proressing down to toes- combines systems (head, assess neuro, mS of upper then later as proceed down assess MS of lower ext) used for complete PW- it minimizes position changes and requires less time Body systems � organized per body systems i.e. lung assessment, abdominal assess, cardiovascular, neuro system best used for focuesd physical assessment May use either approach, just be organized However,the sequence can vary -depending on the age, severity of illness, nurse preferenceor agency priorities or procedures Generally � you should use the same apporach consistently � in case you get interrupted Head to toe Begins at head and progresses down to the toes Most comprehensive Used to obtain baseline information to identify changes in patient status Systems Focuses on one system at a time Cardiac: heart sounds, pulses, capillary refill, B/P Respiratory: breath sounds, rate and depth, skin color Head to toe fashion � organized - everything assessed from head proressing down to toes- combines systems (head, assess neuro, mS of upper then later as proceed down assess MS of lower ext) used for complete PW- it minimizes position changes and requires less time Body systems � organized per body systems i.e. lung assessment, abdominal assess, cardiovascular, neuro system best used for focuesd physical assessment May use either approach, just be organized However,the sequence can vary -depending on the age, severity of illness, nurse preferenceor agency priorities or procedures Generally � you should use the same apporach consistently � in case you get interrupted

12. 12 Assessment techniques Inspection Palpation Percussion Auscultation

13. 13 Assessment techniques - Cont.Inspection Close and careful visualization of the person as a whole and of each body system Ensure good lighting Perform at every encounter with your client

14. 14 Assessment techniques - Cont.Palpation Temperature, Texture, Moisture Organ size and location Rigidity or spasticity Crepitation & Vibration Position & Size Presence of lumps or masses Tenderness, or pain Palpation Techniques Light Deep Bimanual

15. 15 Assessment techniques - Cont.Percussion assess underlying structures for location, size, density of underlying tissue. Direct � sinus tenderness Indirect- lung percussion Blunt percussion-organ tenderness

16. 16 Assessment techniques - Cont.Auscultation Listening to sounds produced by the body Instrument: stethoscope (to skin) Diaphragm �high pitched sounds Heart Lungs Abdomen Bell � low pitched sounds Blood vessels

17. 17 Assessment techniques - Cont.Setting Environment & Equipment Technique General survey Head to toe or systems approach Minimize exposure Areas to assess first � unaffected areas, external before internal parts

18. 18 Physical Health Exam-General Survey Appearance Age, skin color, facial features Body Structure - Stature, nutrition, posture, position, symmetry Mobility - Gait, ROM Behavior Facial expression, mood/affect, speech, dress, hygiene Cognition Level of Consciousness and Orientation (x4) Include any signs of distress- facial grimacing, breathing problems

19. 19 Documentation General Appearance : Alert, and oriented X4; well nourished 40 year old male. Dressed appropriately, well groomed. In no apparent distress (NAD), in good spirits, speech clear, gait steady, and posture relaxed.