health history and physical assessment - …web.cerritos.edu/rsantiago/sitepages/health history and...
TRANSCRIPT
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
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
11
Assessment Sequencing
� Head – to - Toe Assessment
� Body Systems Assessment
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
� Temperature, Texture, Moisture
� Organ size and location� Rigidity or spasticity
� Crepitation & Vibration
� Position & Size
� Presence of lumps or
masses
� Tenderness, or pain
Palpation Techniques
� Light
� Deep
� Bimanual
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 soundsHeartLungs
Abdomen� Bell – low pitched sounds
Blood vessels
17
Assessment techniques - Cont.Setting
� Environment & Equipment
Technique� General survey� Head to toe or systems
approach� Minimize exposure� Areas to assess first –
unaffected areas, external before internal parts
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.
1
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
2
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
3
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
9
Document your Findings – Health History
� Documentation forms vary per agency
� Use of standardized nursing admission assessment forms� Combines health history and physical assessment
4
10
Physical assessment
11
Assessment Sequencing
� Head – to - Toe Assessment
� Body Systems Assessment
12
Assessment techniques
� Inspection� Palpation� Percussion� Auscultation
5
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
� Temperature, Texture, Moisture
� Organ size and location
� Rigidity or spasticity
� Crepitation & Vibration
� Position & Size
� Presence of lumps or
masses
� Tenderness, or pain
Palpation Techniques
� Light
� Deep
� Bimanual
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
6
16
Assessment techniques - Cont.
Auscultation
� Listening to sounds produced by the body
� Instrument: stethoscope (to skin)
� Diaphragm –high pitched sounds
HeartLungsAbdomen
� Bell – low pitched soundsBlood vessels
17
Assessment techniques - Cont.Setting
� Environment & Equipment
Technique� General survey� Head to toe or systems
approach� Minimize exposure� Areas to assess first –
unaffected areas, external before internal parts
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
7
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.