health history and physical assessment

4 main types of health assessments

1. comprehensive

2. ongoing partial

3. focused

4. emergency

comprehensive

Done when someone is admitted

ongoing partial

regular mini checks to track progress

focused

looks at specific issue

emergency

life threatening or unstable issue

health assessment

Collect, validating, and analyzing data.

-subjective

-objective

health assessment includes 2 components

1. health history

2. physical assessment

collecting subjective data

• Sensations or symptoms

• Feelings

• Perceptions

• Desires

• Preference

•  Beliefs

• Ideas

• Values

• Personal information

2 focuses of interviewing

• Establishing rapport and trusting relationship with client.

• Gathering information:

gathering info during interview

1. developmental

2. psychological

3. physiologic

4. sociocultural

5. spiritual status

phases of the interview

1. pre introductory

2. introductory

3. working

4. summary & closing

preintroductory

review patients chart before meeting

introductory

say hello, explain what ur doing, build trust

working

ask questions & gather health history

summary and closing

Wrap up and make sure the patient understands everything

objective data

• What you see, hear, or feel during the physical exam.

• Use your senses and tools like a stethoscope or thermometer

common equipment

• Gloves and gowns

• Sphygmomanometer and

Stethoscope

• Thermometer

• Watch with second hand and

Penlight

• Ophthalmoscope, otoscope

• Ruler or a tape measures

• Doppler, ultrasound

• Tongue depressors, cotton balls,

  tuning fork

non verbal communication

appearance

demeanor

facial expression

attitude

listening

verbal communication

open ended questions

close ended questions

validating

clarifying

reflective

sequencing

directing

non verbal communication to avoid

Excessive or insufficient eye contact

● Distraction and distance

● Standing

verbal communication to avoid

• Biased or leading questions

• Rushing through the interview

• Reading the questions

gerontologic interview

• Slower response

• Sensory changes

• Skin

• Multiple chronic

  conditions

• Fatigue easily

cultural interview

Communication style

Pain expression

Modesty and gender roles

health beliefs

emotional interview

• Anxiety or fear

• Depression

• Anger or

  frustration

• Mental health

  conditions

interaction with anxiety

Be calm and explain things clearly.

interaction with angry

Stay safe and let them vent

interaction with depressed

Be understanding

interaction with manipulative

set clear boundaries

interaction with seductive

• Be professional and get help if needed.

• Set clear boundaries

sensitive topics (death or sexuality )

•  Be respectful

• Do not judge

• Refer to someone else if

  you are unsure

complete health history

1. biographical data

2. reasons for seeking healthcare

3. history of present health concern

4. past family history

5. family health history

6. review of system

7. lifestyle and health practices

8. developmental level

COLDSPA

analysis pain

C: character

O: onset

L: location

D: duration

S: severity

P: pattern

A: associated factors/ how it affects the client

Review of systems

• Integumentary system

• HEENOT system (Head, Ears, Eyes, Nose and Throat)

• Respiratory system

• Cardiovascular system

• Abdominal system

• Breast and Axillae

• Male and Female genitalia includes(rectum, anus, prostate and vaginal)

• Musculoskeletal system

● Neurologic system

prepare setting:

● Private ● Quiet ● Warm ● Well-lit

prepare yourself

● Check your feelings

• ○  Create a calm and supportive environment- don’t bring

  stress into the exam room.

• ○  Wash your hands and wear gloves if needed or any other

  PPE’

prep client

• ●  Explain what’s going to happen

• ●  Be respectful

• ●  Offer privacy when they change clothes

standing

sitting position

sims position

left SIM

patient is lying on left side

-right leg, on top, is bent

-left leg, on bottom, is straight

right sims

patient is lying on right side

-left leg on top is bent

-right leg on bottom is straight

dorsal recumbent

knee chest

left side SIMS is used for:

enema

rectal exam and temp

prone

lithotomy

Nurse must have basic knowledge of three area for physical assessment

• Types & operation of equipment.

• Preparing self and client for physical examination

• Properly perform techniques:

physical assessment techniques

1. inspection

2. palpation

3. percussion

4. ausculation

palpation

touch

percussion

tap

ausculation

listen

Physical Assessment Inspection

• Uses sense of vision, smell, and hearing

• Room at comfortable temperature

• Good lighting

• Look and observe before touching

• Completely expose part being examined while draping the rest of client as appropriate

• Note characteristics

• Compare appearance of symmetric body parts or both sides of any individual body part

physical assessment palpation types

1. light (1 hand, light feel)

2. deep (2 hands, deep feel)

Palpation consists of using parts of the hand to touch and feel for the following characteristics

• ○  Texture (rough/smooth)

• ○  Temperature (warm/cold)

• ○  Moisture (dry/wet)

• ○  Mobility (fixed/movable/still/vibrating)

• ○  Consistency (soft/hard/fluid filled)

• ○  Strength of pulses (strong/weak/thready/bounding)

• ○  Size (small/medium/large)

• ○  Shape (well defined/irregular

• ○  Degree of tenderness

fingerpads sensitive to:

• Pulses

• Texture

• Size

• Consistency

• Shape

• crepitus: air underneath skin

ulnar or palmar surface sensitive to:

Vibrations

Shrills or Thrills

fremitus: feel for vibrations

dorsal surface sensitive to:

temperature

percussion assessment uses:

• ○  Eliciting pain

• ○  Determining location, size, and shape

• ○  Determining density

• ○  Detecting abnormal masses

• ○  Eliciting reflexes

types of percussion

1. direct

2. blunt

3. indirect or mediate

direct percussion

taps sinuses directly with 2 fingers

blunt percussion

hit kidneys with fist and hand

indirect or mediate percussion

2 fingers tapping fingers, respiratory percussion

sounds elicited by percussion

1. resonance

2. hyperresonance

3. tympany

4. dullness

5. flatness

resonance

• Normal sound over healthy lungs

• Medium-loud, low-pitched, hollow

• 🫁 Think: “R” for Respiratory = Resonance

hyperresonance

• Louder & lower-pitched than resonance

• Abnormal in adults – suggests too much air (e.g. emphysema, pneumothorax)

• Can be normal in kids due to thinner chest walls

• 🎈 Think: "Hyper" = Extra Air

tympany

• High-pitched, musical, drumlike

• Heard over air-filled areas, like the stomach or intestines

• 🥁 Think: "Tympany = Tummy"

dullness

• Soft, muffled thud

• Heard over dense organs (e.g. liver, spleen)

• Also heard over consolidated lung tissue (like pneumonia)

• 🪨 Think: “Dull = Dense”

flatness

• Very soft, high-pitched, brief

• Heard over bones, muscles, or tumors

• 🧱 Think: “Flat = Firm”

Before using the stethoscope:

• Warm diaphragm and bell before use

• Explain what you are listening to and answer questions

• Avoid listening through clothes

• Place earpieces into outer ear canal

Diaphragm (flat side):

• Use it with firm pressure

• High-pitched sounds

  • Breath sounds

  • Normal heart sounds

  • Bowel sounds●  Use it with firm pressure

bell (smaller, concave side)

• Light pressure

• Low-pitched sounds

○ Heart murmurs

○ Bruits

physical assessment auscultation

requires use of stethoscope

• Eliminate distracting or competing noise

• expose body part being auscultated

auscultation sounds classified according to

• ○  Intensity (loud or soft)

• ○  Pitch (high or low)

• ○  Duration (length)

• ○  Quality (musical, cracking, raspy)

importnant questions to self

• Did I do the exam properly?

• Are the findings normal or not?

• Should I ask more questions or check other body systems?

• Should I call the doctor or provider?