Health History and Physical Assessment. Rachel S. Natividad, RN, MSN, NP

Transcription

1 Health History and Physical Assessment Rachel S. Natividad, RN, MSN, NP 1

2 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 2

3 Health History Physical Assessment Subjective database Objective database Obtained through interview ID strength, actual or potential health problems, support system, teaching needs, DC and referral needs Obtained by observation and physical assessment techniques Completes the client s health picture Use of effective communications skills 3

4 Complete Health History (Jarvis) Biographical data Reason for Seeking Care History of Present Illness Past Health Accidents and Injuries Hospitalizations and Operations Family History Review of Systems Functional Assessment ( Activities of Daily Living) Perception of Health 4

5 Biographical Data (exercise) Name: Age: Birthplace: Gender: Marital status: Occupation: 5

6 Complete Health History-Cont. Reason for seeking care: 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 6

7 HPI: Analysis of the Symptom P Provokes What makes symptoms better/worse? Q Quality What does pain feel like? R Region/Radiation Where & where does pain go? S Severity On Scale of 1-10 (other scales) T Time When, How often, How long? 7

8 Review of Systems A series of questions re: pt s current and past health including health promotion practices Inquires about signs and symptoms as well as diseases related to each body system 8

9 Document your Findings Health History Documentation forms vary per agency Use of standardized nursing admission assessment forms Combines health history and physical assessment 9

10 Physical assessment 10

11 Assessment Sequencing Head to - Toe Assessment Body Systems Assessment 11

12 Assessment techniques Inspection Palpation Percussion Auscultation 12

13 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 13

14 Assessment techniques - Cont. Palpation Temperature, Texture, Moisture Organ size and location Rigidity or spasticity Crepitation & Vibration Palpation Techniques Light Deep Bimanual Position & Size Presence of lumps or masses Tenderness, or pain 14

15 Assessment techniques - Cont. Percussion assess underlying structures for location, size, density of underlying tissue. Direct sinus tenderness Indirect- lung percussion Blunt percussion-organ tenderness 15

16 Assessment techniques - Cont. Auscultation Listening to sounds produced by the body Instrument: stethoscope (to skin) Diaphragm high pitched sounds Heart Lungs Abdomen Bell low pitched sounds Blood vessels 16

17 Assessment techniques - Cont. Setting Environment & Equipment Technique General survey Head to toe or systems approach Minimize exposure Areas to assess first unaffected areas, external before internal parts 17

18 Physical Health Exam-General Survey Appearance Age, skin color, facial features Body Structure - Stature, nutrition, posture, position, symmetry Mobility - Gait, ROM Behavior Facial expression, mood/affect, speech, dress, hygiene Cognition Level of Consciousness and Orientation (x4) Include any signs of distress- facial grimacing, breathing problems 18

19 Documentation General Appearance : Alert, and oriented X4; well nourished 40 year old male. Dressed appropriately, well groomed. In no apparent distress (NAD), in good spirits, speech clear, gait steady, and posture relaxed. 19

20 Health History and Physical Assessment Rachel S. Natividad, RN, MSN, NP 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 2 Health History Physical Assessment Subjective database Objective database Obtained through interview ID strength, actual or potential health problems, support system, teaching needs, DC and referral needs Obtained by observation and physical assessment techniques Completes the client s health picture Use of effective communications skills 3 1

21 Complete Health History (Jarvis) Biographical data Reason for Seeking Care History of Present Illness Past Health Accidents and Injuries Hospitalizations and Operations Family History Review of Systems Functional Assessment ( Activities of Daily Living) Perception of Health 4 Biographical Data (exercise) Name: Age: Birthplace: Gender: Marital status: Occupation: 5 Complete Health History-Cont. Reason for seeking care: 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 6 2

22 HPI: Analysis of the Symptom P Provokes What makes symptoms better/worse? Q Quality What does pain feel like? R Region/Radiation Where & where does pain go? S Severity On Scale of 1-10 (other scales) T Time When, How often, How long? 7 Review of Systems A series of questions re: pt s current and past health including health promotion practices Inquires about signs and symptoms as well as diseases related to each body system 8 Document your Findings Health History Documentation forms vary per agency Use of standardized nursing admission assessment forms Combines health history and physical assessment 9 3

23 Physical assessment 10 Assessment Sequencing Head to - Toe Assessment Body Systems Assessment 11 Assessment techniques Inspection Palpation Percussion Auscultation 12 4

24 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 13 Assessment techniques - Cont. Palpation Temperature, Texture, Moisture Organ size and location Rigidity or spasticity Crepitation & Vibration Palpation Techniques Light Deep Bimanual Position & Size Presence of lumps or masses Tenderness, or pain 14 Assessment techniques - Cont. Percussion assess underlying structures for location, size, density of underlying tissue. Direct sinus tenderness Indirect- lung percussion Blunt percussion-organ tenderness 15 5

25 Assessment techniques - Cont. Auscultation Listening to sounds produced by the body Instrument: stethoscope (to skin) Diaphragm high pitched sounds Heart Lungs Abdomen Bell low pitched sounds Blood vessels 16 Assessment techniques - Cont. Setting Technique Environment & Equipment General survey Head to toe or systems approach Minimize exposure Areas to assess first unaffected areas, external before internal parts 17 Physical Health Exam-General Survey Appearance Age, skin color, facial features Body Structure - Stature, nutrition, posture, position, symmetry Mobility - Gait, ROM Behavior Facial expression, mood/affect, speech, dress, hygiene Cognition Level of Consciousness and Orientation (x4) Include any signs of distress- facial grimacing, breathing problems 18 6

26 Documentation General Appearance : Alert, and oriented X4; well nourished 40 year old male. Dressed appropriately, well groomed. In no apparent distress (NAD), in good spirits, speech clear, gait steady, and posture relaxed. 19 7