Health History and Physical Exam

Health History and Physical Exam 150 150 Tony Guo

Health History and Physical Exam

 

Assessment

  • Patient’s health history
  • Physical examination
  • Identify patient’s current and past health status
  • Provide baseline for further evaluation
  • Formulate nursing diagnoses

 

Data Collection

  • Medical focus
    • Designed to collect data to be used primarily by the HCP to determine risk for disease and diagnose medical conditions
  • Types of Data
    • Subjective data (symptoms)
      • What the patient says
    • Objective data (signs)
      • What the nurse sees
  • Interview considerations
    • Effective communication is a key factor in the interview process by creating a climate of trust and respect is critical to establishing a therapeutic relationship.
    • You need to communicate acceptance of the patient as an individual by using an open, responsive, nonjudgmental approach. 
    • You communicate not only through language but also in your manner of dress, gestures, and body language
  • Symptom investigation
  • Data organization

Investigation of Patient-Reported symptoms

Factor Questions for Patient and Caregiver Record
P Precipitating and Palliative Were there any events that came before the symptoms? What makes it better or worse? What have you done for the symptom and did it help? Influence of physical and emotional activities. Patient’s attempts to alleviate (or treat) the symptom
Q Quality Tell me what the symptoms feels like (e.g., aching, dull, pressure, burning, stabbing) Patient’s own words (e.g., “Like a pinch or stabbing feeling”)
R Radiation Where do you feel the symptom? Does it move to other areas? Region of body, Local or radiating, superficial or deep.
S Severity On a scale of 0-10, with 0 meaning no pain and 10 being the worst pain you could imagine, what number would you give your symptom? Pain rating number like 7/10 (Moderate to severe)
T Timing When did the symptom start? Any particular time of day, week, month, or year? Has the symptom changed over time? Where you and what were you doing when the symptom occurs? Time of onset, duration, periodicity, and frequency. Course of symptoms. Where patient is and what patient is doing when the symptom occurs

 

Role of Nursing Personnel

  • Role of Registered Nurse (RN)
    • On admission, complete a comprehensive assessment.
    • Obtain patient’s health history by interviewing patient and/or caregiver.
    • Perform physical examination using inspection, palpation, percussion, and auscultation as appropriate.
    • Document findings from the health history and physical examination in the patient’s record.
    • Organize patient data into functional health patterns, if appropriate.
    • Develop and prioritize nursing diagnoses and collaborative problems for the patient.
    • Throughout hospitalization, perform focused assessments based on patient’s history or clinical manifestations.
  • Role of Licensed Practical/Vocational Nurse (LPN/LVN) 
    • Collect and document specific patient data as delegated by the RN (after the RN has developed the plan of care based on the admission assessment).
    • Perform focused assessment based on patient’s history, clinical manifestations, or as instructed by the RN
  • Role of Unlicensed Assistive Personnel (UAP)
    • Take and record vital signs, including oxygen saturation.
    • Report abnormal findings to RN.
    • Measure and document patient’s height and weight, oral intake and output.
    • Report patient’s subjective complaints to RN.
    • Per agency policy, perform point-of-care testing (e.g., glucose) and report findings to RN.

 

Nursing History

  • Subject Data
    • Important Health Information
      • Past health history
  • Major childhood and adult illnesses, injuries, hospitalizations, and surgeries
  • Medications
  • Past and current medications, including prescription and illicit drugs, over-the-counter drugs, vitamins, herbs, and dietary supplements.
  • Question older adult and chronically ill patients about medication routines.
  • Allergies
  • Fully explore the patient’s history of allergies to drugs, latex, contrast media, food, and the environment
  • Surgery or other treatments
  • Record all surgeries, along with the date of the event, reason for the surgery, and outcome
  • Functional Health Patterns
    • Health perception–health management pattern 
  • Ask the patient to describe his or her personal health and any concerns about it
  • Explore the patient’s feelings of effectiveness at staying healthy by asking what helps and what hinders his or her well-being.
  • Ask the patient to rate his or her health as excellent, good, fair, or poor, and record this information in the patient’s own words, if possible
  • The questions for this pattern also seek to identify risk factors by obtaining a thorough family history (e.g., cardiac disease, cancer, genetic disorders), history of personal health habits (e.g., tobacco, alcohol, drug use), and history of exposure to environmental hazards (e.g., asbestos).
  • Nutritional-metabolic pattern
    • If a problem is identified, ask the patient to keep a 3-day food diary for a more careful analysis of dietary intake. 
    • Assess the impact of psychologic factors such as depression, anxiety, stress, and self-concept on nutrition.
    • Determine socioeconomic and cultural factors such as food budget, who prepares the meals, and food preferences.
  • Elimination pattern
  • Activity-exercise pattern
  • Sleep-rest pattern 
  • Cognitive-perceptual pattern
  • Self-perception–self-concept pattern
  • Role-relationship pattern 
  • Sexuality-reproductive pattern 
  • Coping–stress tolerance pattern
  • Value-belief pattern
  • Document the patient’s ethnic background and effects of culture and beliefs on health practices

 

  • Objective Data
    • General Survey
    • Physical Examination
      • Techniques
  • Inspection
  • Visual examination of a part or region of the body to assess normal conditions or deviations and by comparing 
    • Palpation
  • Using light and deep palpation can yield information related to masses, pulsations, organ enlargement, tenderness or pain, swelling, muscular spasm or rigidity, elasticity, vibration of voice sounds, crepitus, moisture, and texture
    • Percussion
  • Technique that produces a sound and vibration to obtain information about the underlying area and a change from an expected sound may indicate a problem.
    • Auscultation
  • Listening to sounds produced by the body with a stethoscope to assess normal conditions and deviations from normal

 

  • Organization of examination
    • Patient comfort, safety, and privacy
    • Follow same sequence every time
  • Recording physical examination

 

Types of Assessment

  • Emergency assessment
    • Limited to assessing life-threatening conditions (e.g., inhalation, injuries, anaphylaxis, myocardial infarction, shock, stroke)
    • This involves a rapid history and examination of a patient while maintaining vital functions.
    • Conducted to ensure survival. Focuses on elements in primary survey (e.g., airway, breathing, circulation, disability)
  • Comprehensive assessment
    • Typically done on admission to the hospital or onset of care in a primary care setting that include detailed health history and physical examination of all body systems.
  • Focused assessment
    • To evaluate the status of previously identified problems and monitor for signs and symptoms of new problems
    • Include abbreviated assessment for the various specific body systems
    • Conducted throughout hospital admission—at beginning of a shift and as needed throughout shift

 

Outline for physical examination

  1. General survey
  • Observe general state of health
  1. Vital signs
  • Record vital signs such as:
  • Blood pressure 
  • Pulse rate (apical/radial pulse)
  • Respiration rate
  • Temperature
  • Oxygen saturation
  1. Integumentary/skin
  • Inspect and palpate skin and nail
  1. Head and neck
  • Inspect and palpate face, sinuses, and central nervous system
  1. Extremities
  • Observe size and shape, symmetry and deformity, and involuntary movements.
  • Inspect and palpate arms, fingers, wrists, elbows, shoulders
  1. Anterior and posterior thorax
  • Inspect for muscular development, scoliosis, respiratory movement, and approximation of AP diameter.
  • Palpate apical impulse, lymph nodes, symmetry of respiratory movement, tenderness of CVA, tumors or swelling, tactile fremitus
  • Percuss for pulmonary resonance
  • Auscultate breath sounds, rate and rhythm, character of S1 and S2 in the aortic, pulmonic, Erb’s point, tricuspid, mitral areas, bruits at carotid, epigastrium
  1. Abdomen
  • Inspect for scars, shape, symmetry, bulging, muscular position and condition of umbilicus, movements
  • Auscultate for peristalsis such as bowel sounds or bruits
  • Percuss then palpate to confirm positive findings; check liver, spleen, and kidney (size and tenderness), urinary bladder (distention)
  • Palpate femoral pulses, inguinofemoral nodes, and abdominal aorta
  1. Neurologic
  • Observe motor status and coordination
  1. Genitalia
  • Male external genitalia
  • Female external genitalia

 

Leave a Reply

Your email address will not be published.