Chapter 4 INSHIRAH QADRI - Weebly

Health HistoryChapter 4

INSHIRAH QADRI

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Assessment

Nursing Process

Planning

implementation

Evaluation

Assessment

Diagnosis

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Health Assessment

Health is complete physical, mental and social wellbeing and not merely the absence of disease or inability. (WHO, 1948).

Health assessment is the collection of data about the individual’s health status.

purpose of the health history is to collectSubjective dataObjective data

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Steps of health assessment are:

✓Collection of subjective data

✓Collection of Objective data

✓ Validation of data

✓ Documentation of data

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Subjective Data

Is sensations and symptoms (ex. Pain, hungers)

feeling (ex. Happiness and sadness), perception,

desires, belief, values and personal information.

*Symptom is a subjective sensation that the

person feels from the disorder.

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Objective Data

Information about client that nurse directly

observe during interaction and information

obtained through physical assessment

(examination).

*Sign is an objective abnormality that you as

the examiner could detect on physical

examination or in laboratory reports.

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Health History

Types of Health History:

➢ Comprehensive health assessment

➢ Focused or problem oriented assessment

➢ Follow-up history

➢ Emergency history

# All history information is considered subjective data

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The Health History

Comprehensive Focused

▪ For new admissions

▪ Baseline for

future assessments

▪ Platform for

health promotions

▪ Provides fundamental

knowledge about the patient

▪ Strengthens nurse-patient

relationship

▪ Appropriate for established

patients

▪ Addresses focused

concerns or symptoms

▪ Assesses symptoms

restricted to a specific

body system.

Health History

Components of Comprehensive Health History:

• Biographic data (identifying data) & source of history

• Reason for seeking care (Chief complaint)

• History of present illness (HPI)

• Past history (PHx)

• Family history

•Review of body systems

•Health patterns & functional assessment (activities of

daily living [ADLs])

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Biographical Data

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Age )Birth date(,Gender, Birth place, Ethnic origin, Marital status, occupation, Health insurance, & Address and phone number.

When documenting initial information please do not forget about documenting date and time of history taking, source of history (e.g.: patient, family member, friend), reliability, and your name.

The Health History

Chief Complaint(s)

Report symptoms and signs that were main cause of

visiting the hospital/clinic.

* Please use patient’s own words / do not use diagnostic

statements.

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The Health History

History of Present Illness

Seven Attributes of a Symptom

OLD CART•Onset

•Location/ radiation

•Duration

•Characteristic symptom / symptom dimensions

(i.e., severity / intensity, quality, distress it cause)

Quality: burning, sharp, dull, aching,

gnawing,throbbing, shooting.

•Associated manifestation

•Relieving / Exacerbating

•Treatment / self-treatment (over-the-counter [OTC [ ) 12

Past Health

➢ Childhood illnesses

➢ Accidents or injuries

➢ Adult serious or chronic illnesses

➢ Hospitalizations

➢ Operations

➢ Obstetric history

➢ Medications

➢ Allergies

➢ Health maintenance (Immunizations, Last examination date)

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Family History

The Health History

•Age and health or cause of death of blood relatives

•Health of close family members (spouse, children)

•Family history of various conditions such as heart

disease, high blood pressure, stroke, diabetes, blood

disorders, cancer, obesity, mental illness, and others

•Family tree (genogram)

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Genogram

Weight

◦Balance scale

◦Recommended range for height

Height

VITAL SIGNS❑BLOOD Pressure

❑Heart Rate

❑Respiration Rate

❑Temperature

❑Pain

Review of Body Systems

The Health History

General overall health assessment for different body

systems namely:

Skin, hair, head, eyes, ears, nose and sinuses, mouth and

throat, neck, axilla, respiratory system, cardiovascular

system, urinary system, gastrointestinal system,

peripheral vascular system, endocrine system,

hematology system, neurologic system, musculoskeletal

system. 16

Health Patterns and Functional Assessment

The Health History

Personal and social history of the patient that may influence

health and illness.

Examples:

Self-perception, health-perception, activity-exercise, sleep-

rest, nutrition, coping-stress-tolerance, role-relationship,

value-belief, personal habits (tobacco), environmental

hazards, occupational health, family violence.

Health Patterns

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Assessment Techniques

Chapter 6

INSHIRAH QADRI

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Physical Examination

Techniques of physical examination:InspectionPalpationPercussionAuscultation

•Palpation

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Inspection:

▪ Using the senses of vision, smell and hearing to observe and detect any normal and abnormal findings.

▪ Always comes first and begins once you see the client.▪ Concentrated watching: first look to the whole body and then

each system.

▪ Compare patient’s right side with left side.

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Guidelines must be followed when performing inspection:

• Make sure the room is in comfortable temperature.

• Privacy of the patient and right to refuse.

• Explain the procedure before beginning.

• Use good lightening.

• Completely expose the body part you are inspectingwhile covering the rest of the client.

• Use of certain instruments such as penlight, otoscope

• Choose appropriate time

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PalpationApply the sense of touch to assess

PalpationUsing parts of the hand to touch and feel for the following ch.ch:

❑Texture- rough/smooth.

❑Temperature-warm/

cold.

❑Moisture- dry/wet.

❑Organ location and size

❑Swelling

❑Consistency -soft/ hard/

fluid filled.

❑Mobility-fixed/movable.

▪ Rigidity or plasticity

▪ Crepitation

▪ Vibration / pulsation

▪ Presence of masses

▪ Presence of tenderness

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Palpation

Using different parts of the hands Finger tips—for fine tactile discrimination, as of skin texture,

swelling, pulsation, and superficial masses.

A grasping action of the fingers and thumb—to detect the position, shape, and consistency of an organ or mass

The dorsa (backs) of hands and fingers—for determining skin temperature

Base of fingers (metacarpophalngeal joints)

or ulnar surface of the hand— for vibration


Types of Palpation:

▪ Light P. = to detect surface characteristics, circular motion 1cm depth

▪ Moderate P. = to detect body organs and masses, Circular motion ,1-2cm depth

▪ Deep P. = to detect deep structure characteristics,2.5 – 5cm depth

▪ Bimanual palpation: Use two hands one on each side of the body part ( kidney, spleen).

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Guidelines must be followed when performing

palpation

▪ Should be slow and systematic.

▪ Begin with light palpation.

▪ Use gentle and calm approach.

▪ Hands should be warm

▪ Short nails.

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Percussion:

Is tapping the person’s skin with short, sharp, strokes that yield a palpable vibration and a characteristic sound that depicts the location, size, and density (air, fluid, solid) of the underlying organs.

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Percussion may also be used for:• Detecting abnormal superficial mass (2-3 cm size, 5-7 cm deep).

•Eliciting pain if the underling structure is inflamed.• Eliciting a deep tendon reflex using the percussion hammer.

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Percussion: Notes

Characteristics of Percussion Notes

Type Amplitude Pitch Quality Duration location

Resonant Medium –

loud

Low Clear, hollow Moderate Lung

Hyperresonant Louder Lower Booming Longer Lung filled

with air

Tympany Loud High Drum like Longest Intestine

Dull Soft High Muffled thud Short Liver or

spleen

Flat Very soft High A dead stop

of sound

Very soft Bone or

muscle


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Auscultation: Is listening to sounds produced by the body such as the heart, blood vessels, lungs, and the abdomen using the stethoscope. Use good quality stethoscope with two end pieces:Diaphragm: for High-pitched sounds such as breath, bowel, normal heart sounds.Bell: for low-pitched sounds such as extra heart sounds or murmurs.

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Guidelines for auscultation:

➢ Eliminating distracting noises from the environmental.

➢ Expose body part . Don’t auscultate through clothing.

➢Use appropriate part of the stethoscope.

➢Keep instrument clean.

➢Warm the stethoscope and the room.

➢Avoid your own artifact (as your thumb, your breathing).

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Beginning the examination:

• Check your equipment.• Adjust the lighting and environment.• Take permission. • Explain procedure.• Privacy. • Make the patient comfortable.•Choose the sequence of examination.• Consider the person's emotional status.•Avoid distraction.•Proper documentation.•Summarize finding for the patient.

DO NOT FORGET TO THANK THE CLIENT


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Be sure to wash your hands before and after the procedure.

Clean the environment and equipment.

When dealing with body fluids such as blood or pus, use protective barriers namely gloves, gowns, aprons, masks, protective eye wear.

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General SurveyChapter 7

INSHIRAH QADRI

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As mentioned before a complete physical assessment includes general survey, vital signs, body measurements, and a head to toe system examination.

General Survey:

General Survey

General Survey is a study of the

whole person, covering the health

state and obvious physical

characteristic. It is first step of

complete physical examination.

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General Survey

General survey consists of:

1) Physical Appearance:Age (appears her age)

Sexual development (appropriate for gender)

Level of consciousness: awake, alert, and oriented

(time, person, place)

Skin color: even pigmentation, intact, no lesions.

Facial features: symmetric with movement

Facial expressions during conversation and

assessment.

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General Survey

2) Body Structure:Stature: height appropriate to age

Nutrition: weight appropriate to height and age;

body fat distribution even.

Symmetry: body parts equal bilateral

Posture: stand comfortably

▪ plumb line; line passes through anterior ear,

shoulder, hip, patella and ankle.

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General SurveyBody Structure:

Position: sits comfortably, arms relaxed at sides, head

turned to examiner.

Body build, contour

▪ Arm span; fingertip to fingertip equals height.

▪ Body length; from crown to pubis roughly equal to

length from pubis to sole.

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General Survey

3) Mobility:

A) Gait: foot placement accurate, smooth even and

well-balanced walk with symmetric arm swing.

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General Survey

B) Range of motion: full ROM for each joint.

Accurate, smooth, and coordinated movement.

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General Survey

4) Behavior

▪ Facial expression; maintains eye contact,

expressions app to situation

▪ Mood and affect: comfortable and cooperative

▪ Speech: articulation -able to form ward -clear and understandable

▪ Dress: app. to climate, clean, fits the body

▪ Personal hygiene; clean and groomed

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General Survey

5) Odor of the body and breath:▪ Fruity odor (acetone) for diabetic patients,

alcohol odor, pulmonary infection, urine.

6) Signs of Distress:▪ Cardiac or respiratory distress : shortness of

breath, cyanosis.

▪ Pain: facial expressions.

▪ Anxiety, depression

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Body Measurement

Physical Measurement▪ Weight▪ HeightPhysiological Measurement (Vital signs)▪ BLOOD Pressure▪ Heart Rate▪ Respiration

Rate444444▪ Temperature▪ Pain

Require equipment✓ Balance scale✓ Recommended range for

height✓ Vital signs equipment's✓ Pain scale

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Chapter 4 INSHIRAH QADRI - Weebly