Fundamentals of Nursing: Health History & Physical Exam

Fundamentals of Health History and Physical Examination

The Patient Interview

The patient interview is a critical initial step in the clinical assessment and is structured into three distinct phases:

• Orientation Phase: The beginning of the interaction where the relationship is established and the purpose of the interview is defined.

• Working Phase: The core of the interview where the clinician gathers data, discusses health concerns, and explores the patient's history.

• Termination Phase: The conclusion of the interview where information is summarized, and the next steps are outlined.

Several factors significantly influence the success of a patient interview:

• Privacy: Ensuring the patient feels secure to share sensitive information.

• Interruptions: Minimizing external disruptions to maintain focus.

• Environment: Creating a comfortable and professional setting.

• Communication Techniques: Utilizing effective verbal and non-verbal methods to facilitate dialogue.

Data Collection and Review of Systems

Health history is gathered through the collection of two types of data:

• Subjective Data: Information provided by the patient regarding their feelings, perceptions, and self-reported symptoms.

• Objective Data: Observable and measurable data obtained through physical examination and diagnostic testing.

Review of Systems (ROS): This systematic inquiry begins with an assessment of the patient's general health status before moving into specific body systems.

Preparation for Physical Assessment

Physical Environment and Equipment

The physical environment must be optimized for assessment by ensuring:

• Adequate privacy for the patient.

• Proper lighting to observe physical characteristics accurately.

• Sufficient space to move around the patient.

• Temperature control for patient comfort.

Equipment Management:

• All necessary tools should be arranged in the order they will be utilized.

• Equipment must be prepared and pre-checked to ensure proper functioning before the assessment begins.

Patient Preparation and Safety

Before the examination starts, the follows steps must be taken:

• Identity Verification: Ensuring the correct patient is being assessed.

• Elimination Needs: Offering the patient the opportunity to use the restroom.

• Dressing and Coverage: Providing proper gowns and covers to maintain modesty and privacy.

• Needs Assessment: Meeting both the emotional and safety requirements of the patient.

Professional Standards and Integration

• Privacy and Confidentiality: Maintaining strict adherence to personal chart review protocols and data protection.

• Positioning: Grouping assessment techniques by the patient's position (e.g., sitting, supine) to limit the frequency of position changes.

Integrated Assessment Approaches:

• Complete Physical Examination: A thorough head-to-toe assessment.

• Focused Assessment: Concentrating on a specific problem or body system.

• Preventive Care: Screenings and assessments focused on health maintenance.

• Systematic Approach: Utilizing a consistent method to ensure no areas are overlooked.

Basic Assessment Techniques

There are four primary techniques used during a physical examination:

Inspection

This involves the use of vision and smell to examine the characteristics of the whole person as well as individual body systems. It is the first step in any assessment.

Palpation

Touch is used to assess body organs and skin characteristics such as texture, temperature, and moisture.

• Deep Palpation: Used to identify abdominal masses or organ size.

• Bimanual Deep Palpation: Utilizing both hands to entrap or feel specific deep structures.

Percussion

This involves tapping the skin with short, sharp strokes to cause a vibration. The resulting sounds are used to determine the location, size, and density of underlying structures.

Auscultation

The process of listening to sounds produced by body organs or systems, usually using a stethoscope to evaluate the heart, lungs, and abdomen.

General Survey

The general survey is the first component of the physical exam, providing an overall impression of the patient. Components include:

• Demographics: Age, race, sex, and gender identity.

• Social Identity: Sexual orientation.

• Appearance: Clothing, hygiene, and grooming standards.

• Psychological State: Affect and mood.

• Behavioral Observations: Safety concerns, speech patterns, and gait.

• Substance Use: Assessment of alcohol, tobacco, or recreational drug use.

• Vital Signs and Anthropometrics:

  • Vital sign assessment.

  • Measurement of height, weight, and Body Mass Index (BMI).

Integumentary Assessment

Skin Inspection

Initial inspection focuses on skin color alterations:

• Absence of pigment: Lack of melanin.

• Cyanosis: Bluish discoloration.

• Erythema and Purpura: Redness or bleeding under the skin.

• Jaundice: Yellowing of the skin or sclera.

• Pallor: Paleness.

• Vitiligo: Patchy loss of skin pigmentation.

Skin Lesions and Malignancies

• Lesion Classification: Categorized as primary or secondary lesions.

• Malignancy Screening: Evaluated using the ABCDE criteria.

Palpation of Skin, Hair, and Nails

• Skin Attributes: Texture, temperature, and turgor (elasticity).

• Edema: Assessment for swelling, specifically looking for pitting edema.

• Hair and Scalp: Inspection and palpation for quality and integrity.

• Nails: Inspection for shape and palpation for capillary refill time.

Head, Ears, Eyes, Nose, and Throat (HEENT)

The Head and Eyes

• Head: Assessment of position, skull contour, symmetry, and the presence of spasmodic muscular contractions or tics.

• Eye Structure and Function:

  • Alignment and positioning.

  • Lids, eyebrows, conjunctiva, and sclera.

  • Cornea and lens clarity (screening for cataracts).

  • Lacrimal glands and pupillary reflexes (accommodation).

  • Extraocular movement (EOM).

• Internal Eye Structures: Optic disc, retinal vasculature, fovea, macula, and vitreous body.

• Visual Acuity: Determined using the Snellen chart or the E chart.

• Tools: Use of the ophthalmoscope for internal visualization.

The Ears and Hearing

• External Ear: Inspection of the auricle (pinna), lobule, and tragus for alignment, shape, and position.

• Internal Ear: Otoscopic examination to check the external auditory canal, tympanic membrane, and the presence of cerumen (earwax) or discharge.

• Hearing Evaluation:

  1. Conductive Hearing Loss: Interference with sound transmission.

  2. Sensorineural Hearing Loss: Damage to the inner ear or auditory nerve.

  3. Mixed Hearing Loss: A combination of both.

• Hearing Tests: Weber test and Rinne test.

• Equilibrium: Assessed via the Romberg test.

Nose, Sinuses, and Mouth

• Nose and Sinuses: Inspection and palpation of the external nose and frontal/maxillary sinuses.

• Oral Cavity:

  • Dental assessment (teeth).

  • Inspection of oral mucosa, gums, tongue, uvula, tonsils, and palate.

  • Evaluation of the jaw.

The Neck and Lymphatics

• Vascular Structures: Inspection of jugular veins and carotid arteries.

• Organs: Palpation of the thyroid gland and trachea.

• Lymph Nodes: Systematic palpation of:

  • Preauricular, Postauricular, and Occipital nodes.

  • Parotid and Retropharyngeal (tonsillar) nodes.

  • Submandibular (submaxillary) and Submental nodes.

  • Anterior cervical, Posterior cervical, and Supraclavicular nodes.

Respiratory Assessment

Inspection and Palpation

• Thoracic Cage: Inspection of the shape and configuration of the chest.

• Breathing: Evaluation of breathing patterns and identifying abnormal findings.

• Palpation:

  • Tactile Fremitus: Feeling for vibrations while the patient speaks.

  • Chest Excursion: Evaluating the symmetry of chest expansion.

Auscultation

• Breath Sounds: Listening for normal and adventitious (abnormal) sounds.

• Atelectasis: Identifying areas of collapsed lung tissue.

Cardiac and Peripheral Vascular Assessment

Heart Assessment

• Inspection and Palpation: Identifying the apex and localized pulsations.

• Auscultation:

  • Heart sounds ($S1$ through $S4$).

  • Identification of dysrhythmias.

  • Pulse Deficit: The difference between apical and radial pulse rates.

  • Cardiac Murmurs: Categorized on a scale from Grade $1$ to Grade $6$.

  • Bruits: Abnormal blowing or swishing sounds heard over arteries.

Peripheral Vascular Assessment

• Pulse Intensity Scale:

  • $0$: Absent pulse.

  • $1$: Diminished pulse.

  • $2$: Normal pulse.

  • $3$: Bounding pulse.

• Pulse Locations: Brachial, radial, femoral, popliteal, and pedal (dorsalis pedis and posterior tibial).

• Diagnostic Tests: Allen test (for radial/ulnar flow) and Doppler assessment (for non-palpable pulses).

Venous and Arterial Insufficiency

• Physical Findings: Varicose veins, dependent edema, and phlebitis.

• The Five Ps of Arterial Occlusion:

  1. Pain

  2. Pallor

  3. Pulselessness

  4. Paresthesia

  5. Paralysis

• Trophic Changes: Lack of hair growth, recurring ulcers, and brittle or thin skin.

Musculoskeletal and Neurological Systems

Musculoskeletal System

• Postural Irregularities: Inspection for deviations in spinal alignment or limb symmetry.

• Function: Assessment of mobility and muscle strength.

Neurological Assessment

• Structural Divisions: Central Nervous System (CNS) and Peripheral Nervous System (PNS).

• Cranial Nerves: Assessment of all $12$ cranial nerves in numbered order.

• Sensory Nerve Assessment: Mapping sensation via dermatomes.

• Motor and Coordination:

  • Gross motor skills.

  • Fine motor skills.

  • Balance.

Reflexes

Reflex Response Scale:

• $4+$: Very brisk, hyperactive with clonus.

• $3+$: Brisker than average, slightly hyperactive.

• $2+$: Average, normal.

• $1+$: Sluggish or diminished.

• $0$: No response.

Mental and Emotional Status

Mental Status Assessment

Evaluation of cognitive functions including:

• Intellect, memory, and knowledge.

• Language, speech, and communication.

• Judgment, decision-making, and abstract thinking.

• Association, attention, and Level of Consciousness (LOC).

Emotional Assessment

• Demeanor: The patient's outward behavior.

• Facial Expressions: Congruence with stated mood.

• Stress: Identifying overt signs of emotional distress.

Abdominal and Genitourinary Assessment

Abdominal Assessment

1. Inspection: Checking for symmetry and surface characteristics.

2. Auscultation: Must be performed before palpation. Listening for borborygmi (hyperactive bowel sounds) and bruits.

3. Palpation: Final step to check for tenderness or masses.

Breasts and Genitalia

• Breasts: Inspection for symmetry and palpation for masses in both males and females.

• Female Genitalia: Comprehensive inspection and palpation.

• Male Genitalia:

  • Penis: Inspection and palpation.

  • Scrotum and Testes: Inspection and palpation for abnormalities.

Completion of the Physical Assessment

Following the examination, the clinician must ensure:

• Patient Recovery: Allowing time for the patient to dress and offering necessary supplies (e.g., tissues).

• Environment: Returning the examination area to its original condition.

• Infection Control: Utilizing Personal Protective Equipment (PPE) and following infection control protocols.

• Documentation: Prompt recording of the assessment in the Electronic Health Record (EHR).

• Reporting: Seriously abnormal or questionable findings must be reported to the appropriate provider and the report itself documented.

• Education: Documenting any patient education provided during or after the examination process.