Health History & Physical Assessment

Comprehensive Admission Assessment

health assessment done when someone is admitted

Ongoing Partial Assessment

regular mini checks to track progress

Focused Assessment

looks at a specific issue

Emergency Assessment

life threatening or unstable issue

Health Assessment

collect, validating, and analyzing data

either subjective or objective data

includes two components → health history and physical assessment

Subjective Data

what the patient is telling you

sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information

Interviewing

requires professional and interpersonal skills

establishes rapport and trusting relationship with the client

gathers info on developmental, psychological, physiologic, sociocultural, and spiritual status

can help identify changes and collaborate interventions or strengths that can help with client

Preintroductory Phase

review patients chart before the meeting

Introductory Phase

say “hello” and explain what you’re doing, build trust

Working Phase

ask questions and gather health history

Summary and Closing Phase

wrap up and make sure the patient understands everything

Objective Data

what you can see, hear, or feel during the physical exam

use your senses and tools like a stethoscope or thermometer

Assessment Equipment

gloves and gowns

sphygmomanometer (BP cuff) and stethoscope

thermometer

watch with second hand and penlight

ophthalmoscope and otoscope

ruler or a tape measure

doppler and ultrasound

tongue depressors, cotton balls, and tuning fork

Non Verbal Communication

appearance, demeanor, facial expression, attitude, listening

Verbal Communication

open ended questions and closed ended questions

validating, clarifying (for more info), reflective, sequencing, and directing (clear concise responses asking about a specific issue)

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

readings the questions straight from paper

Gerontologic Considerations

slower responses, sensory changes, skin changes, have multiple chronic conditions, fatigue easily

ex: a 75 year old may not show typical fever response in infection - you must look for confusion or changes in behavior instead

Cultural Considerations

communication style, pain expression, modesty and gender roles, and health beliefs

ex: a patient from East Asia might not openly complain about pain due to values of endurance

Emotional Considerations

anxiety or fear, depression, anger or frustration, and mental health conditions

ex: a patient with anxiety may have difficulty focusing on questions so use a calm tone and simple instructions

Interaction with Anxious

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, don’t judge, and refer to someone else if you are unsure

Health History

biographical data → name, age, insurance info

reasons for seeking healthcare

history of present health concerns

past health history

family health history

review of body systems

lifestyle and health practices

developmental level

COLDSPA

mnemonic to analyze pain

character, onset, location, duration, severity, pattern, 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 (rectum, anus, prostate, vagina)

musculoskeletal system

neurologic system

sometimes also mental/emotional status

Setting Up Environment

make sure the room is private, quiet, warm, and well lit

Preparing 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

Preparing the Client

explain whats going to happen

be respectful

offer privacy when they change clothes

Standing and Sitting

for posturing and lung checks

Supine

for general exams

Sims

left side for rectal temp and enemas → laying on left side with right leg bent

Dorsal Recumbent

Knee Chest

Prone

Lithotomy

for pelvic exams

Physical Assessment

nurse must have knowledge on types and operation of equipment

prepare yourself and the client for the exam

properly preform techniques

inspection → look

palpation → touch

percussion → tap

auscultation → listen

Inspection

uses sense of vision, smell, and hearing

room at comfortable temperature with good lighting

look and observe before touching

completely expose part being examined while draping the rest of client

note characteristics and compare appearance of symmetric body part

Palpation

light → 1 hand

deep → 2 hands

consists of using parts of the hand to touch and feel for the following characteristics - fingertips, dorsal, or palmar surface used

texture → rough or smooth

temperature → warm or cold

moisture → wet or dry

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

finds discriminations like pulses, texture, size, consistency, shape, or crepitus (air under skin respiratory)

Ulnar or Palmar Surface

feels vibrations, shrills/thrills (chest vibration), or fremitus (vibrations when saying 99 that weaken further down the body)

Dorsal Surface

feels temperature

Percussion

used to elicit pain, determine location/size/shape, determine density, detect abnormal masses, and elicit reflexes

types → direct, blunt, and indirect or mediate

elicits resonance, hyperresonance, tympany, dullness, or flatness

Direct Percussion

tapping directing on the body part

ex: tapping on sinuses

Blunt Percussion

hitting body air hard with fit

ex: palpating kidneys with a light punch

Indirect Mediate Percussion

placing your hand on the body part and tapping that with your fingers

ex: respiratory exams

Resonance

low pitch and hollow normal sound

Hyperresonance

louder booming lower pitch sound, air in thoracic cavity

Tympany

high pitch and hollow sound over areas of air in the abdomen

Dullness

dull sound heard over an organ

Flatness

no sound if tapping over bone

Stethoscope

earpieces into outer canal with binaurals angled down toward the nose

before use warm diaphragm and bell, explain what you are doing and answer questions, and avoid listening through clothes

Diaphragm

the larger side used to hear high pitch sounds like breath sounds, normal heart sounds, and bowel sounds

use it with firm pressure

Bell

smaller side used to hear lower pitch sounds

use with low pressure to hear heart murmurs and bruits (whooshing over carotid area)

Auscultation

requires use of a stethoscope

sounds rated on intensity (loud/soft), pitch (high/low), duration, and quality (musical/cracking/raspy)

eliminate distractions or competing noise and expose body part being used

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?

Flushing

redness

caused by blushing, alcohol, fever, injury, or infection

Cyanosis

bluish color

due to cold envi and cardiac or respiratory disease

Jaundice

yellowish

caused by liver disease

Pallor

paleness

due to anemia

Ecchymosis

purplish discoloration

Petechiae

small hemorrhagic spots caused by capillary bleeding

Lesion

diseased or injured tissue

Turgor

fullness or elasticity of the skin

Bruits

abnormal swooshing or blowing sounds heard over a blood vessel

Edema

excess fluid/swelling of tissue

tested by pressing into skin, skin will have indent

Dehydration

decreased skin elasticity and skin folds return slowly

Pupillary Reaction

darken room and briefly shine light into eyes → pupils should constrict

Accommodation

place object 10-15cm from patients nose and most closer and farther away

closer → pupils constrict

farther away → pupils dilate

Convergence

hold finger 6-8 inches from face and move closer → pupils cross