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

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