Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Health History and Physical Assessment Lecture 1

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Health History and Physical Assessment

Lecture 1


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


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


Historical information often comes from a variety of sources, including

• The patient

• The family

• Friends

• Other observers


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


Biographical Data• Name:

• Age:

• Gender:

• Marital status:

• Occupation:


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


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?


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


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


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


Review of Systems

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


Physical assessment


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


Assessment techniques

• Inspection• Palpation• Percussion• Auscultation


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


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


Assessment techniques - Cont.Percussion

• Technique that translates the application of physical force into sound

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


Percussion Technique


Percussion Sounds

Tympany Gastric bubbleHyperresonance Emphysematous lung

Resonance Healthy lungDullness LiverFlattness Muscle


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

the body

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

soundsHeartLungsAbdomen

• Bell – low pitched soundsBlood vessels


Nutritional Assessment• BMI• Dietary data

– Food record– 24-hour recall– Diet diary

• Conducting the Dietary Interview• Cultural and religious considerations


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

Documents

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Health History and Physical Assessment Lecture 1