Health History and Physical Examination Obtaining a patient’s health history and performing a physical examination are activities by the nurse during the assessment phase of the nursing process The purpose- to make a clinical judgmnet or Dx about the pt’s health status

Data Collection

Nursing Focus Types of Data Subjective=symptoms Objective=signs Interview Considerations Subjective data, pt interview, Health portability and Accountability Act HIPAA for pt’s privacy rule, pt can get a copy of their health records. Symptom Investigation Location, quality(what does it feel like?), quantity(how often), Chronology(When was the first time it occurred?), aggravating or alleviating factors(what makes it better or worse?) etc… Data Organization Gordon's 11 functional health pattern NANDA developed Taxonomy II with 13 domains See the table in your textbook

Nursing History: Subjective Data Important Health Information – Past health history – Medications – Surgery or other treatments

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

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

Physical Examination: Objective Data General Survey Physical Examination – Techniques Inspection: Visual exam Palpation: use of touch Percussion: the production of sounds by rapid strike Auscultation: listening to sounds by stethoscope

Abdominal Palpation

Auscultation

Percussion

Physical Examination: Objective Data