Health History Physical Assessment 2012[1]

7/30/2019 Health History Physical Assessment 2012[1]

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Health Assessment


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Health assessment contains health

history,

vital signs,

general surveyand

physical assessment


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Client and environment require special consideration

Keep the client informed

Be organizeddemonstrate respect for the clients apprehension

Appear calm, organized and competent at the bedside

Adjust environment according to the client

s need(special accommodations), quiet, warm and well lit

Gather equipment

Positioning and draping

Preparing


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Purpose of the Health History

Health history is a review of the clients functional health

patterns prior to the current contact with a health care agency,focuses on: functional health patterns, responses to changes in

health status, and alterations in lifestyle.

Used in developing the plan of care and formulating nursing

interventions.

HEALTH HISTORY


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Purpose of physical health examination is to evaluate thephysiologic outcomes of health care and thus the progress of aclients health problem


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Demographic info: name, address, date of birth, gender,

religion, race, ethnic origin, occupation, insurance

Reason for seeking health care: this should be put in thepatients own words, its pt actual report

Clients perception of health status: clients opinion of his/her

general health

Previous illnesses, hospitalizations, and surgeries

Subjective dataElements of health history


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Family history of acute or chronic illnesses that tend to be

familial

Immunizations, exposure to communicable disease

Allergies

Current medications

Psychosocial history

Value and belief system

Health history cont


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Sociocultural history

Activities of daily living

1. Nutrition

2. Elimination

3. Rest/sleep

4. Activity/exercise

Review of systems(ROS)-pain assessment

Health history cont


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Physical assessment

Height , weight, v/s, (general survey)

Physical exam can be head to toe exam, focused exam of a

body part, or body system

Conducted in an aseptic, systematic and efficient manner

Objective data


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General survey; clients physical appearance, mood and

behavior, signs and symptoms of distress

Document data in an organized format, use proper terminology

and agency-approved abbreviations

Physical assessment


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1. Inspection

2. Palpation

3. Percussion

4. Auscultation (see hand-out)

Techniques


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1. Integumentary system (hair, scalp, skin and nails)2. Head and Neck (skull, face, eyes, ears, nose,

mouth, pharynx, and neck)

3. Thorax and Lungs

4. Heart and Vascular system

5. Lymphatic system

6. Abdomen

7. Genitalia

8. Musculoskeletal system

9. Neurologic system

Systems


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Skin

Hair and Scalp

Nails

Skin assessment provides a noninvasive window toobserve the bodys physiological functions.

Integumentary system


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Color

Lesions

Moisture

Temperature

Texture

Mobility and Turgor

Edema

SKIN


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Thorax and Lungs

Landmarks for inspection, auscultation, and percussion

Anterior and posterior examination

Shape and symmetry

Thoracic expansion

HEART AND LUNGS


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Auscultation of Normal Breath Sounds

1. Vesicular sounds

2. Bronchovesicular sounds

3. Bronchial sounds


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Auscultation of Adventitious Breath Sounds

Crackles

Rhonchi

Wheezes

Pleural friction rub

Stridor


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Heart

Landmarks for inspection, palpation, auscultation

Heart sounds

Palpation for thrills and heaves

Abnormal auscultatory findings

Murmurs

Bruits


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Vascular System

Blood perfusion of peripheral vesselsPeripheral pulses compared bilaterally

Skin temperature, color


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Measurements

Capillary Refill: Push on the tip of the great toe or the nail bed until

blanching occurs. Then release and note how long it takes for the red color

to return, a reflection of blood inflow to the distal aspect of the lower

extremity. Longer then 2-3 seconds is considered abnormal and consistent

with arterial insufficiency.

Edema: There is a very subjective scale for rating edema which ranges

from "trace at the ankles" to "4+ to the level of the knees." After examining

many patients, you'll develop a sense of what is a lot and what is not.

Pulses: Theseare rated on a scale ranging from 0 (not palpable) to 2+(normal). As with edema, this is very subjective and it will take you a while

to develop a sense of relative values. In the event that the pulse is not

palpable, the doppler signal generated is also rated, ranging again from 0

to 2+.


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Inspection

Contour

Symmetry

Umbilicus

Surface motion

Scars

Abdomen


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Auscultation

All four quadrants in a systematic fashion

Beginning with the RLQ

Tympany

Dullness

BruitsHyperactive or hypoactive bowel sounds


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Light palpation in all four quadrants beginning with

the RLQ Resistance

Tenderness

Rebound tenderness

Organ enlargement

Abdomen


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Inspection

Palpation

Range of Motion (ROM)

Bilateral Comparison

Joints

Arthritis

Osteoarthritis

Crepitus

Musculoskeletal system


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Mental Status

Appearance

Level of alertnessSpeech

Behavior

Awareness of environment, also referred to as orientation

Mood

Affect: flat ,excitable, appropriate.

Thought ProcessThought Content

Memory

Judgment

Higher cortical functioning and reasoning


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WakefulnessUnresponsive, Sleepy, Drowsy, Awake, Alert

(Eye Opening None to spontaneous in Glascow Coma Scale)

Identifies person, place, time typically, but circumstances

may prevent those steps if medicated or unfamiliar with

environment

Confusion

Orientation

Memory defects of all kinds, intermittent or constant

(Delirium b/c illness or medication OR depression, or dementia)


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Observations for Documentation

Skin LesionsColor

Associated pain, redness, heat, swelling

Size and location

Pattern of eruption (macular, papular, scaling,

oozing, etc.)

Distribution (linear, circular, symmetric

Wounds Wound bedWound edges and margins

Wound size (in cm)

Surrounding skinCondition of dressing removed

Odor, exudate

Careful documentation of findings of all wounds

is essential for legally sensible practice

Health History Physical Assessment 2012[1]

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