Health History and Physical Assessment

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Health History and Physical Assessment

• Rachel S. Natividad, RN, MSN, NP

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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

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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 clients health picture

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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

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Biographical Data (exercise)

• Name
• Age
• Birthplace
• Gender
• Marital status
• Occupation

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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

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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?

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Review of Systems

• A series of questions re pts current and past
  health including health promotion practices
• Inquires about signs and symptoms as well as
  diseases related to each body system

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Document your Findings Health History

• Documentation forms vary per agency
• Use of standardized nursing admission assessment
  forms
• Combines health history and physical assessment

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Physical assessment
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Assessment Sequencing

• Head to - Toe Assessment
• Body Systems Assessment

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Assessment techniques

• Inspection
• Palpation
• Percussion
• Auscultation

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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

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Assessment techniques - Cont.Palpation

• Palpation Techniques
• Light
• Deep
• Bimanual

• Temperature, Texture, Moisture
• Organ size and location
• Rigidity or spasticity
• Crepitation Vibration
• Position Size
• Presence of lumps or masses
• Tenderness, or pain

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Assessment techniques - Cont.Percussion

• assess underlying structures for location, size,
  density of underlying tissue.
• Direct sinus tenderness
• Indirect- lung percussion
• Blunt percussion-organ tenderness

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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

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Assessment techniques - Cont.Setting

• Technique
• General survey
• Head to toe or systems approach
• Minimize exposure
• Areas to assess first unaffected areas,
  external before internal parts

• Environment Equipment

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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

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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.