The Complete Health History, Physical examination techniques, and Pain Assessment

1. The Complete Health History, Physical examination techniques, and Pain Assessment Zyad Saleh J U School of Nursing

2. Introduction Nursing Process

4. Introduction Definition of Health Assessment Health assessment is the collection of data about the individual’s health status. It may be subjective or objective. It is analyzing and synthesizing that data, making judgments about the effectiveness of nursing interventions, and evaluating client care outcomes

5. Introduction Why to do health assessment? The purpose of health assessment is to collect subjective and objective data; to determine client’s over all level of functioning in order to make professional judgment (planning, implementation).

6. Introduction what types of data are collected? Physiologic psychological sociocultural developmental, and spiritual

7. Introduction Subjective Data They are sensations and symptoms (ex. Pain, hungers) feeling (ex. Happiness and sadness), perception, desires, belief, values and personal information that can be elicited and verified only by the client *Symptom is a subjective sensation that the person feels from the disorder. # All history information is considered subjective data

8. Introduction Subjective Data • Biographical information (name, age, religion, occupation) • History of present health concern: Physical symptoms related to each body part or system (e.g., eyes and ears, abdomen) • Personal health history and Family history • Health and lifestyle practices (e.g., nutrition, activity, relationships, cultural beliefs or practices, family structure and function, community environment)

9. Introduction Objective Data Information about client that nurse directly observe during interaction and information obtained through physical assessment (examination). Obtained by general observation and by using the four physical examination techniques: inspection, palpation, percussion, and auscultation.

10. Introduction Objective Data • Physical characteristics (e.g., skin color, posture) • Body functions (e.g., heart rate, respiratory rate) • Appearance (e.g., dress and hygiene) • Behavior (e.g., mood, affect) • Measurements (e.g., blood pressure, temperature, height, weight) • Results of laboratory testing (e.g., platelet count, x-ray) Signs: is an objective abnormality

11. The Health Assessment Types of Health Assessment: • • Initial comprehensive assessment • • Ongoing or partial assessment • • Focused or problem-oriented assessment • • Emergency assessment

12. The Health Assessment Types of Health Assessment: • • Initial comprehensive assessment • needed when the client first enters a health care system • to establish baseline data against which future health status changes can be measured and compared.

13. The Health Assessment Types of Health Assessment: • • Initial comprehensive assessment involves: • subjective data • past health history, • family history, • and lifestyle and health practices • objective data gathered during a step-by-step physical examination.

14. The Health Assessment Types of Health Assessment: • • Ongoing or partial assessment • consists of data collection that occurs after the comprehensive database is established.

15. The Health Assessment Types of Health Assessment: • • Focused or problem-oriented assessment • consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem. • • Emergency assessment • a very rapid assessment performed in life-threatening situations

16. Introduction Steps of health assessment are: • Collection of subjective and Objective data • Organizing data • Validation data • Documentation data

17. Data Collection Methods(interview) • Collecting subjective data is an integral part of interviewing the client to obtain a nursing health history. • Interviewing is a planned communication or a conversation with a purpose • Establishing rapport and a trusting relationship with the client to elicit accurate and meaningful information • Gathering information on the client’s developmental, psychological, physiologic, sociocultural, and spiritual statuses

18. Data Collection Methods(interview) • PHASES OF THE INTERVIEW: • Introductory • working, • and summary and closing phases.

19. Data Collection Methods(interview) • PHASES OF THE INTERVIEW: • Introductory • introducing examiner to the client, • explains the purpose of the interview, • discusses the types of questions that will be asked, • explains the reason for taking notes, • and assures the client that confidential information will remain confidential.

20. Data Collection Methods(interview) • PHASES OF THE INTERVIEW: • working, • biographic data, • reasons for seeking care, • History of present health concern, • past health history, family history, • review of body systems for current health problems, lifestyle • and health practices, and developmental level.

21. Data Collection Methods(interview) • PHASES OF THE INTERVIEW: • summary and closing phases. • summarize information obtained during the working phase • identify and discuss possible plans to resolve the problem • make sure to ask if anything else concerns the client and if there are any further questions.

22. Data Collection Methods(interview) • involves two types of communication— • nonverbal • and verbal.

23. Data Collection Methods(interview) • involves two types of communication— • nonverbal • appearance, demeanor, posture, facial expressions, and attitude strongly influence how the client perceives the questions you ask.

24. Open-ended questions • invite clients to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings. • They typically begin with the words “how” or “what.” “How have you been feeling lately?” • Discuss broad topic and invites answers longer than one or two words. • give clients the freedom to provide only the information that they are ready to disclose. • The open-ended question is useful at the beginning of an interview or to change topics and to elicit attitudes.

25. Closed questions • restrictive and generally require only “yes” or “no” or short factual answers giving specific information. • “When did your headache start?” • Closed questions are often used when information is needed quickly, such as in an emergency situation. • The highly stressed person and the person who has difficulty communicating will find closed questions easier to answer than open-ended questions.

26. Planning and Interview Setting • Time • Client free of pain • Limited interruptions • Place • Private • Comfortable environment • Limited distractions • Seating Arrangement • Hospital, office or clinic, group • 45 degree for pt in bed • Distance • Comfortable (60-90 cm) • Language • Use easily-understood terminology • Interpreter or translator • Stages of interview • Opening or introduction • Establish rapport • Orientation • Body or development • Closing

27. The Health History • The health history is an excellent way to begin the assessment process • purposes: • provide the groundwork for identifying nursing problems • and provide a focus for the physical examination.

28. The Health History Components of Comprehensive Health History:

30. The Health History

31. History of Present Illness Each principal symptom should be well-characterized, with descriptions Of Seven Attributes

32. The Health History Past History • Past illnesses • Past surgeries, hospitalizations, & accidents. • Obstetric history. • Psychiatric • Allergies • Medications • Health maintenance (ex. Immunizations, safety measures, screening test, risk factors, environmental hazards) Please include dates

33. The Health History Family History: Include maternal and paternal grandparents, aunts and uncles on both sides, parents, siblings, and the client’s children. • Health of close family members (spouse, children) • Age and health or cause of death of blood relatives • Family history of various conditions such as heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, obesity, mental illness, and others • Family tree (genogram)

34. Genogram helps organize and illustrate family history

36. The Health History Review of Body Systems General overall health assessment for different body systems: Skin, hair, head, eyes, ears, nose and sinuses, mouth and throat, neck, axilla, respiratory system, cardiovascular system, urinary system, gastrointestinal system, peripheral vascular system, endocrine system, hematology system, neurologic system, musculoskeletal system. Skin: Rashes, lumps, sores, itching, dryness, changes in color; changes in hair or nails; changes in size or color of moles.

37. *When documenting initial information please do not forget about documenting date and time of history taking, source of history (ex. patient, family member, friend), reliability, and your name.

38. Physical Examination • Physical examination is an objective part of health assessment. • As health history, physical examination may be complete or focused. • A complete Physical Examination includes general survey (is an overall review or first impression a nurse has of a person’s well being), vital signs, body measurements, and a head to toe system examination. • A focused assessment concentrates on specific systems related to the problem.

40. Physical Examination Techniques of physical examination: • Inspection • Palpation • Percussion • Auscultation

41. Physical Examination Inspection: • Using the senses of vision, smell and hearing to observe and detect any normal and abnormal findings. • Always comes first and begins once you see the patient. • Concentrated watching: first to the whole body and then each system • Requires good lighting, adequate exposure, time, and use of certain instruments such as penlight, otoscope.

42. Physical Examination Ch .Ch. nurse may observe during inspection : #Color, Patterns, size, location, consistency, symmetry, movement, behavior, orientation, appearance, odors and sounds. #Compare the appearance of symmetric body parts ( eye, ears, arms, hands, thorax…), symmetry in movement.

43. Physical Examination • Guidelines must be followed when performing inspection: • Make sure the room is in comfortable temperature. • Privacy of the patient and right to refuse. • Explain the procedure before beginning. • Use good lightening. • Look and observe before touching. • Completely expose the body part you are inspecting while covering the rest of the client.

44. Physical Examination Palpation Using parts of the hand to touch and feel for the following ch.ch: Texture (rough/smooth), Temperature (warm/ cold), Moisture (dry/wet), Mobility (fixed/movable), Consistency (soft/ hard/ fluid filled), Vibration/Strength of pulse (strong/weak/ thready/ bounding), Shape (well defined/ irregular), Organ location and size, swelling, presence of masses, Rigidity/spasticity, Tenderness.

45. Physical Examination • Parts of hand to use when palpating: • Finger pads sensitive to Fine discrimination : pulses, texture, size, consistency, shape, crepitus, swellings, lumps. • Ulnar or palmar surface, base of fingers sensitive toVibration. • Dorsal surface (back of the hand) sensitive to Temperature.

46. Physical Examination Types of Palpation: • Light palpation: with no pressure. Is used to feel the surface of the structure using circular motion, pulses, tenderness, surface skin texture, temperature and moisture. • Moderate palpation: depress skin surface 1-2 cm with the dominant hand with circular motion. Is used to feel palpable body organs and masses , and to note size, consistency, and mobility of structures.

47. Physical Examination • Deep palpation: Depress a skin surface between 2.5 – 5 cm by Placing non-dominant hand on the top of the dominant one. Is used to feel deep organs.

48. Physical Examination • Bimanual palpation: Use two hands one on each side of the body part ( kidney, spleen). Use one hand to make pressure and other to feel structure. Note the size , shape, consistency, and mobility of the structure.

49. Physical Examination Palpation: • Should be slow and systematic. • Begin with light palpation. • Use gentle and calm approach, worm hands. • Short NAILS.

50. Physical Examination Percussion: Is tapping the person’s skin with short, sharp, strokes that yield a palpable vibration and a characteristic sound that depicts the location, size, and density (air, fluid, solid) of the underlying organs.