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

2. 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

3. 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

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

5. 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

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

7. 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

8. 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)

9. 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

10. Physical Assessment

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

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

13. 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

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

15. 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

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

17. 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)

18. 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.