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

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

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

Complete Health History-Cont. Biographical Data (exercise) Name: Age: Birthplace: Gender: Marital status: Occupation:

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

Complete Health History-Cont. HPI: Analysis of the Symptom P Provokes Q Quality R Region/Radiation S Severity T Time

Complete Health History-Cont. 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

Exercise Interview a client (your partner) and obtain the following: Reason for seeking care History of present illness (including Analysis of the symptom/complaint PQRST) Review of Systems (Complete PQRST for any positive symptom)

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

Physical Assessment

Physical Assessment- Cont. Assessment Sequencing & Techniques Head – to - Toe Assessment Body Systems Assessment Inspection Palpation Percussion Auscultation

Assessment techniques - Cont. Inspection Ensure good lighting Perform at every encounter with your client

Assessment techniques - Cont. Palpation Palpation Techniques Light- rigidity, tenderness, masses Deep – enlarged organ, tenderness, masses Bimanual-position, size, tenderness Temperature, Texture, Moisture Organ size and location Rigidity or spasms Crepitation & Vibration Position & Size Lumps or masses Tenderness or pain

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

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

Assessment techniques - Cont. Environment & Equipment Proceed as follows: General survey Head to toe or systems approach Minimize exposure Assess – unaffected areas & external parts first

Physical Assessment- Cont. General Survey Appearance Age, skin color, facial features Include any signs of distress- facial grimacing, breathing problems 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)

Documentation General Survey : Alert, and oriented X4; speech clear. Well nourished 40 year old male. Dressed appropriately, clean & well groomed. In no apparent distress (NAD), mood and affect appropriate for situation, gait steady, and posture relaxed.