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

2. HISTORY and PHYSICAL ASSESSMENT OBJECTIVES
Discuss different methods and the sequencing used for basic physical assessment for each body system
Describe the components of the complete health history
Identify significant findings of a health history and physical assessment of a patient
Discuss the normal assessment and common abnormal findings for each body system
Successfully complete a physical assessment practicum

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

4. 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

5. Biographical Data (exercise)
Name:
Age:
Birthplace:
Gender:
Marital status:
Occupation:

6. 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

7. HPI: Analysis of the Symptom
P Provokes What makes symptoms better/worse?
Q Quality What does pain feel like?
R Region/Radiation Where & where does pain go?
S Severity On Scale of 1-10 (other scales)
T Time When, How often, How long?

8. 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
The review of systems is a useful method for gathering medical information in an orderly fashion. This review is a series of questions about the person's current and past medical experiences. It usually proceeds from general to specific information. A thorough record of relevant dates is important in determining relevance of past illnesses or events to the current condition. A review of systems typically follows a head-to-toe order.
So as not to omit anything that pt may have forgotten to report. Or feel is not important to report.
If no specific complaint about a system, do a ROS on that system as part of subjective data

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

10. Physical assessment
Validates the patient’s complaints related to health
Assists in formulating nursing diagnoses and interventions
Monitors current health problems
Obtains baseline information for future assessments

11. Assessment Sequencing
Head – to - Toe Assessment
Body Systems Assessment
Head to toe
Begins at head and progresses down to the toes
Most comprehensive
Used to obtain baseline information to identify changes in patient status
Systems
Focuses on one system at a time
Cardiac: heart sounds, pulses, capillary refill, B/P
Respiratory: breath sounds, rate and depth, skin color
Head to toe fashion – organized - everything assessed from head proressing down to toes- combines systems (head, assess neuro, mS of upper then later as proceed down assess MS of lower ext)
used for complete PW- it minimizes position changes and requires less time
Body systems – organized per body systems i.e. lung assessment, abdominal assess, cardiovascular, neuro system
best used for focuesd physical assessment
May use either approach, just be organized
However,the sequence can vary -depending on the age, severity of illness, nurse preferenceor agency priorities or procedures
Generally – you should use the same apporach consistently – in case you get interrupted

12. Assessment techniques
Inspection
Palpation
Percussion
Auscultation

13. Assessment techniques - Cont. Inspection
Close and careful visualization of the person as a whole and of each body system
Ensure good lighting
Perform at every encounter with your client

14. Assessment techniques - Cont. Palpation
Palpation Techniques
Light
Deep
Bimanual
Temperature, Texture, Moisture
Organ size and location
Rigidity or spasticity
Crepitation & Vibration
Position & Size
Presence of lumps or masses
Tenderness, or pain

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

16. 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

17. Assessment techniques - Cont. Setting
General survey
Head to toe or systems approach
Minimize exposure
Areas to assess first – unaffected areas, external before internal parts
Environment & Equipment

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

19. Documentation General Appearance :
Alert, and oriented X4; well nourished 40 year old male. Dressed appropriately, well groomed. In no apparent distress (NAD), in good spirits, speech clear, gait steady, and posture relaxed.