1. INTRODUCTION TO HEALTH ASSESSMENT NUR123 Spring 2009 K. Burger, MSEd, MSN, RN, CNE PPP by: Victoria Siegel RN, CNS, MSN Sharon Niggemeier RN, MSN Revised by: Kathleen Burger 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 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 2 nd 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 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 = 5 th vital sign Utilize pain scale Understand chronic vs acute pain Recognize gender, transcultural and developmental factors effecting pain