Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Health History and...

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Health History and Physical Assessment

Lecture 1

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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

• Use of effective communications skills

• Objective database

• Obtained by observation and physical assessment techniques

• Completes the client’s health picture

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Historical information often comes from a variety of sources, including

• The patient

• The family

• Friends

• Other observers

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Complete Health History

• Biographical data• Chief complain• History of Present Illness • Past Health history• Family History • Functional Assessment ( Activities of Daily

Living): Diet, sleeping, exercise, coffee, alcohol, drugs, tobacco

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Biographical Data• Name:

• Age:

• Gender:

• Marital status:

• Occupation:

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Complete Health History-Cont.• Chief complain: 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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Analysis of the Symptom• What What makes symptoms better/worse?

• Describe What does pain feel like?

• Where Where & where does pain go?

• How On Scale of 1-10 (other scales)

• When When, How often, How long?

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Past Health history• Major childhood & adult illnesses• Accidents and Injuries • Hospitalizations and Operations• Immunizations & dates: reactions to immunizations• Surgery: Dates, Complications• Medications: Current, past• Allergies: Medications, environmental, food.• Transfusions: Reactions, date & # of units if known• Emotional status: Mood disorders, psychiatric attention

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Family History • Any family members with illness• Age of parents: Age & cause of death if deceased• Age & number of siblings: Health Status• History of chronic diseases (ex: Hx of heart disease,

hypertension, cancer, TB, diabetes, asthma, STD's, kidney, thyroid disease)

• Major genetic disorders & health problems

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Father died at age 43 in train accident. Mother died at age 67 of stroke; had varicose veins, headaches One sister, died in infancy of unknown cause. Husband died at age 54 of heart attack Daughter, 33, with migraine headaches, otherwise well; son, 31, with Headaches

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Review of Systems

• Inquires about signs and symptoms as well as diseases related to each body system

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Physical assessment

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Physical Assessment• Usually performed after the health history• Examiner must wash hands • Make the patient comfortable • Assessment must be systematic and organized

• Head – to - Toe Assessment

Assessment Sequencing

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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

• Temperature, Texture, Moisture• Organ size and location• Rigidity or spasticity

• Crepitation & Vibration

• Position & Size

• Presence of lumps or masses

• Tenderness, or pain

Palpation Techniques

– Light

– Deep

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Assessment techniques - Cont.Percussion

• Technique that translates the application of physical force into sound

• Assess underlying structures for location, size, density of underlying tissue.

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Percussion Technique

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Percussion Sounds

Tympany Gastric bubbleHyperresonance Emphysematous lung

Resonance Healthy lungDullness LiverFlattness Muscle

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Assessment techniques - Cont.Auscultation• Listening to sounds produced by

the body

• Instrument: stethoscope (to skin)• Diaphragm –high pitched

soundsHeartLungsAbdomen

• Bell – low pitched soundsBlood vessels

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Nutritional Assessment• BMI• Dietary data

– Food record– 24-hour recall– Diet diary

• Conducting the Dietary Interview• Cultural and religious considerations

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Clinical AssessmentIndicators of Nutritional Status• General appearance• Skin, hair, and nails• Mouth; includes teeth and gums• Neck; includes thyroid• Musculoskeletal • Abdomen• Nervous system• Height and weight