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Health History and Physical Assessment

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Percussion. Auscultation. 13. Assessment techniques - Cont. Inspection ... Percussion. assess underlying structures for location, size, density of underlying tissue. ... – PowerPoint PPT presentation

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Title: Health History and Physical Assessment


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

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
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

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
Biographical Data (exercise)
  • Name
  • Age
  • Birthplace
  • Gender
  • Marital status
  • Occupation

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
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
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

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
Physical assessment
11
Assessment Sequencing
  • Head to - Toe Assessment
  • Body Systems Assessment

12
Assessment techniques
  • Inspection
  • Palpation
  • Percussion
  • Auscultation

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
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

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
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
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

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
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.
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