1. INTRODUCTION TO HEALTH ASSESSMENT
TECHNIQUES OF PHYSICAL ASSESSMENT
GENERAL SURVEY

2. Health Assessment Is holistic data collection AND analysis
Utilizes the nursing process
Incorporates critical thinking.

3. Health Assessment
Includes knowledge of developmental stages throughout the life cycle
Includes physical,mental,psychosocial assessment along with assessment for domestic violence, elder abuse and child abuse

4. Health Assessment
Requires proficient communication skills and interviewing techniques
Requires the establishment of rapport and trust
Considers cultural aspects

5. Health Assessment: The Health History
Begins with reason for seeking care (chief complaint is previously used term) & health history
Document using the patient’s own words
Elicit a complete description from patient
Document duration of complaint
What aggravates condition, what may alleviate it?

6. Types of Health Histories
Complete
Interval
Problem focused or chief complaint

7. History Taking
Well developed interview skills and careful documentation
Environment conducive to privacy and comfort
Is the client a good historian?
Reasons for seeking health care
Interview- intro, working, termination phases

8. Complete Health History
Biographical
Reason for seeking health care
Present health/Illness
Past health
Family health
Review of systems
Psychological
Functional Assessment
Perception of health

9. Present Health/Illness Reason for seeking care
Onset, duration, precipitating factors.
Frequency, duration…
Associated symptoms i.e. N/V
Alleviating/ aggravating factors
ROS re: CC
Relevant family, occupational or recreational history.

10. Past Health History Past general health Childhood illnesses
Accidents/ injuries
Hospitalizations/surgeries
Acute and chronic illnesses
Immunizations
Allergies, medications, transfusions
Obstetric History

11. Current Health Habits Meds (including OTC/Herbal/Vitamins) Exercise
Sleep

12. Family History Important to know to determine risks
Status of family members Parents, siblings, grandparents
Status of spouse/significant other and Children
Construct Genogram

13. Review of Systems: ROS
Review past and present health status of each body system.
Review health maintenance.
A Head-to- Toe approach
May elicit new information

14. Psychological Function
Cognitive – memory, comprehension
Response to illness and health
Psych history, meds, anxiety?
Cultural considerations

15. Functional Assessment
ADLs
Sleep/rest
Nutrition/problems with diet, weight
Alcohol /Substance abuse
Smoking history (in pack years)
Coping difficulties
Domestic/ child abuse

16. Perception of Health How one defines health
Views on one’s health status
What are one’s expectations pertaining to health and health care

17. Physical Examination (PE)
Goal is to identify variations from normal.
Explain procedure first
Head to Toe
Unaffected areas before affected

18. Techniques of PE Four components used in specific order: Inspection
Palpation
Percussion
Auscultation

19. Techniques of PE
Inspection- First techniques used. What examiner sees, hears and smells. Observe symmetry.
Palpation- Second technique using fingers and hands to touch. Light palpation first then deep palpation

20. Techniques of PE
Percussion- Third technique…tapping on skin surface which creates a vibration of underlying structures. The vibration produces a sound, may aid in diagnosis.
Resonant- normal lung.
Hyperresonant- Child’s lung or emphysema.
Tympany- Air filled organ, e.g., stomach or intestine.
Dull- Dense organ, e.g., liver or spleen.
Flat- No air present, e.g., bone.

21. Techniques of PE
Uses for Percussion: Mapping out location and size of an organ
Determining density (air, fluid, solid) of a structure
Detecting superficial mass (up to 5 cm deep)
Eliciting pain if underlying structure is inflamed
Eliciting a DTR using a percussion hammer

22. Techniques of PE
Auscultation-Usually last technique during PE (*exception – abdomen, it’s the 2nd technique after inspection)
Use stethoscope to block sounds not magnify
Diaphragm-firmly against skin
Bell- lightly against skin

23. Auscultation Description of sounds heard
Pitch- frequency of sound vibrations, high or low.
Intensity- loudness of sound: loud or soft (amplitude)
Duration- length of sound: short, long
Quality- subjective terms- harsh, tinkling, etc…

24. Physical Exam Utilize 4 techniques Proper setting Equipment
Clean/ safe environment
Remember client comfort

25. Summary
Health assessment includes:
Complete health history
ROS
Physical Exam

26. General Survey Study of the whole individual Overall impression
Begins at the first encounter with a person
Introduction to the physical assessment
Composed of 4 parts: physical appearance, body structure, mobility & behavior

27. General Survey Stature Age Nutrition Sex Symmetry LOC Posture
Physical Appearance
Age
Sex
LOC
Skin color
Facial features
Body Structure
Stature
Nutrition
Symmetry
Posture
Position
Body contour

28. General Survey Mobility Gait Range of Motion (PROM or AROM) Behavior
Facial expression
Mood
Speech
Dress/Hygiene

29. General Survey Includes Height & Weight
Vital signs: Temperature, Pulse, Respiration & Blood Pressure
Recognize transcultural considerations
Note S/S (signs/symptoms) of distress/pain

30. Assessing Distress/Pain
Assessment includes:
S- Severity
L- Location
I- Influencing factors
D- Duration
A- Associated Symptoms

31. Assessing Distress/Pain
Pain assessment = 5th vital sign
Utilize pain scale
Understand chronic vs acute pain
Recognize gender, transcultural and developmental factors effecting pain