Health History and Physical Examination Chapter 3 Overview Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Data Collection Medical Focus 2 Table 3-1. Medical History Format. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Data Collection Nursing Focus Types of Data Interview Considerations Symptom Investigation Data Organization 3 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Data Collection 4 Fig Obtaining a nursing history is an important role of the nurse. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Culturally Competent Care Assessment 5 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing History: Subjective Data Important Health Information  Past health history  Medications  Surgery or other treatments 6 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing History: Subjective Data Functional Health Patterns  Health perception–health management pattern  Nutritional-metabolic  Elimination pattern  Activity-exercise pattern  Sleep-rest pattern  Cognitive-perceptual pattern 7 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing History: Subjective Data Functional Health Patterns, continued  Self-perception–self-concept pattern  Role-relationship pattern  Sexuality-reproductive pattern  Coping–stress tolerance pattern  Value-belief pattern 8 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Examination: Objective Data General Survey Physical Examination  Techniques  Inspection  Palpation 9 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Examination: Objective Data 10 Fig Palpation is the examination of the body through the use of touch. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Examination: Objective Data Physical Examination  Techniques, continued  Percussion  Auscultation 11 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Examination: Objective Data 12 Fig Auscultation is listening to sounds produced by the body to assess normal conditions and deviations from normal. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Examination: Objective Data 13 Fig Percussion technique. Tapping the interphalangeal joint. Only the middle finger of the nondominant hand should be in contact with the skin surface. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Examination: Objective Data Physical Examination, continued  Equipment 14 Table 3-4. Equipment for Physical Examination*. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Examination: Objective Data Physical Examination, continued  Organization of examination 15 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Examination: Objective Data Physical Examination, continued  Recording physical examination 16 Table 3-6. Gerontologic Differences in Assessment. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Types of Assessment Comprehensive Assessment Focused Assessment Emergency Assessment 17 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Types of Assessment Learning Assessment 18 Table 3-8. Clinical Application of Various Types of Assessment. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Problem Identification and Nursing Diagnoses 19 Fig Problem identification phase of the nursing process. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.