Health Assessment
B/S bv Chapter 5
The Value of History Taking
• The history directs the focus of the physical exam
• The history often is the basis for forming the diagnosis
• Keys to obtaining a history successfully
– Develop a atmosphere of trust
– Learn to ask the right questions
– Gain skill in interpreting the responses
– Know what to do next
– Care begins simultaneously during the history
When Taking the H&P:
- The nursing process is utilized: Assess, Nrsg. Dx., Plan, Implement,
Evaluate
- The information is critical for identifying physical & psychological
problems the patient is experiencing
- Health history & physical assessment are performed by the nurse (RN)
- Performed under various settings: clinics, acute care, outpatient office, longterm care, school, home
- Explain to patient purpose of health hx & PE, how this information will be
used.
So I can determine and plan the course of your care
So that I can plan your educational program
First Impressions are important
• A positive first impression is necessary to start the “trusting relationship”,
between you and the pt.
• This begins with the initial contact
– Appearance should be clean, neat, professional
– Approach with confidence
– Demeanor
– Body language- yours and theirs
• Shake hands- provides opportunity for making initial observation
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Establishing the Patient Relationship
Polite introduction
– Is the pt. made to feel like an invited guest or an unwanted pest?
– Be respectful of person, space, property & family
– Determine how the pt. wants to be addressed; Desired name
– Avoid disrespectful terms & voice tone (consider age & culture)
Patient Relationship (cont’)
– Location and Position of the interview is important
– Quiet & Private location, if possible
– Is it possible to make the pt more comfortable?
– Make eye contact and keep position should be at eye level
– Appropriate distance and position promotes
– Safety
– Respect of Personal zone
Elements of the Comprehensive History
Include:
• First Impressions and the environment
• Identifying data
• Chief complaint or concerns
• History of present illness
• Current health status and medical care
• Significant past history
• Family history
• Systems review
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Patient info
– Look at the pt’s. records: labs, med. HX, diagnostic tests, medical/nurse’s
notes
– What was said in nursing report
(SBAR)
– What is the “reported” chief complaint(s)?
The Patient’s environment
– What is the setting?
– Are medical documents available or on file? Are they assessable?
– What is the setting like?
– Is the patient undergoing medical therapy or under medication at the time
of interview?
Identifying Data (Biographical data)
•Name, age, DOB, Sex
•Race/ cultural factors/ religious practices
•Current care provides
•Language preferences/ cultural factors
•Current care provides – address parents of children in order to establish trust
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The Chief complaint
What is the single most critical concern to the pt.?
– “What seems to be the problem today?”
– “What can I help you with today?”
– Which system (origin) do you believe to be affected by the Chief Complaint?
– Do you clearly understand the pts. chief complaint or complaints?
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Are there multiple complaints?
“if I could make one thing better for you, which would you want it to be?”
Are the multiple complaints likely related?
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– Will you need to address multiple issues?
– Could some of these be chronic issues?
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Tips for effective history taking
Ask open-ended questions:
• “What seems to be bothering you today?” - Opens them up to talk
Closed- ended questions
• “Is your chest pain sharp or dull?” – having to answer yes or no.
You may ask Multiple choice questions
Listen actively!!!
• Act as if you are listening, learn forward towards the patient, eye
contact.
• Repeat the pt’s. statements
• Clarify answers if needed
• Take notes if you have to, but write briefly. Don’t bury yourself looking
down on paperwork
• Display your concern
• Confront with caution
Hx. Of present illness
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Explore the CC in more detail
Explore other complaints
– Are they associated?
– do they involve different body systems?
Current Health status & medical care
what medical therapies or treatment are they undergoing?
What medications are they taking? Get Name, dose, route, frequency if
possible
Who is the regular physician? Are there specialists who are seeing them?
Allergies, what kind of reaction do they experiece?
Home situation, daily life, family life
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Are there any recent changes to diet? Recent wt. gains/loss – was it
intentional?
Any recent changes in sleep pattern? What do they do to help themselves
sleep?
Tobacco, alcohol, substance abuse – how much (on a daily or weekly
basis)
Type of occupation
Immunizations, flu shots, pneumonia vaccines, - when was the last time
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Significant Past history
What is the general state of health as per the pt. (subjective)
Significant adult or childhood illnesses or injuries
Psychiatric illnesses
Past hospitalizations, surgeries, or long-term treatments – why?
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Family History
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Relative risk factors
– DM, HTN, Renal dis., heart dis.’
– early acute MI, early sclerotic coronary disease, stroke,
– Asthma, allergies, cardiac dysrrhythmias,
– Cancer, osteoporosis, mental illness
Review of Systems
R.O.S. – is an overview of the pt’s general health - usually subjective
– System reviews is usually focused by the chief complaint
- questions are asked about each major body systems in terms of past
or
- present symptoms.
– “Are you having any problems with your bladder?” (nocturia,)
– You want to Act on the chief complaint by
– Directing immediate care as appropriate
– Hx taking may need to be temporarily deferred (ex: respiratory distress)
– Interpret the feedback and Act
– What do I think of these responses the patient is making?
– Do they make sense?
– Am I missing something?
– Do I need clarification?
– Use your knowledge of A&P and pathophysiology to assess and ask
questions
– Why is the pt. experiencing these signs and symptoms?
– Create a picture of what is happened to this pt. today
Sensitive Topics
Topics such as: abuse, rape, personal issues
Is it the right location or place to talk privately with the patient
– Does anyone present make the pt. feel uncomfortable
Can you gain their trust?
Choosing appropriate words to show sensitivity
Understand the pts. feelings related to the sensitive nature
Be very professional
The silent patient
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Short periods of silence may be normal
Allow them time to collect their thoughts
Provide reassurance and encouragement
Consider:
– That the patient may be frightened; or perhaps you frightened them
– Are you dominating the discussion?
– Have you offended the pt.?
– Is there is a physical or mental disorder? Or a lack of understanding?
The overly talkative pt.
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Allow the pt. to speak
If necessary, politely interrupt and focus the discussion
– Focus on more critical issues
– Ask specific, closed-ended questions
– Summarize the pt’s. story and move on
– Don’t display your impatience
The anxious frightened patient
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Look for signs of anxiety or fear
Try to alleviate concerns and develop trust
Do not give false reassurance
– “Everything is going to be fine”
Identify the source of anxiety/fear
Try to understand the pts. Feelings – “I don’t know why you are so
anxious, would you like to talk about it?”
The Angry Hostile Patient.
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These are common feelings associated with stress or fear
Understand the source of these feelings
Respond in a professional & caring manner.
Personal safety is a primary concern!!!
– Distance
– Assistance
– Firm but let your verbal and body language show that you care
The intoxicated Patient
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Irrational
Altered sense of right and wrong
May become violent
If the pt. is shouting,
– Increased potential for violent behavior
– Listen
– Don’t respond back with shouting
The Depressed or Suicidal pt.
Know the warning signs
Explore the specific feelings of the pt.
– Be direct and specific
– Question regarding thoughts of suicide or personal harm
– Talk openly and specifically about suicide plans
The Patient with a Confusing
History or Behavior
The entire story does not add up
Assess mental status
Consider possible dementia or delirium
– Identify cause if possible
– Consider specific causes based upon behavior
The Patient with a Language Barrier
Extremely difficult to assess
Enlist friends or family to act as interpreter
Use pre-established questions in the pts. Language
Language lines
Intelligence and Literacy
– Does the pt. really understand your question?
– History may be inaccurate
– Enlist caregiver or family
– Can the pt. actually read?
Patients with Sensory Deficits
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Hearing impaired
– Does the pt. read lips?
– Face the pt when talking to them
– Stand close to the good ear
– Talk slowly and distinctly
– Use a Sign language interpreter
– Place a sign to alert others of pt. needs
– Don’t yell – does the patient wear hearing aids? Where are they?
- Blindness: your voice and touch are critical at this point to Establish a
trusting relationship
Common pitfalls
Using a tone of voice that sends the wrong message
– “What is your problem today, Mr. Jones?”
– Why did you push the call bell?
(Patients impression)
– He thinks I call for every little problem
– I must have called and was not supposed to
– I think I’m bothering these nice people
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Lack of respect for cultural, religious or ethnic differences
– “Why do you people use these home herbal remedies?”
– “You have enough kids. You should consider birth control”
(Patients Impression)
This person thinks I am a fool
She laughs at the traditions of my culture
He does not respect my personal decisions
Poor choice of words or using technical terms
– How many years has your husband been using these ace inhibitors
– Your wife is experiencing congestive heart failure
– Have you voided?
(Patients impression)
– What the heck is he talking about?
– My wife’s heart is failing?!?! Has her heart stopped yet?
– Son, could you speak English?
Summary
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Obtaining the history guides the physical exam
History taking is accomplished along with the physical exam and therapies
• Nurse obtains health history
Role of Nurse
Biographical data – age, wt./ht., culture, religious practices,
Past health history
Family history – genogram (family tree diagram of identifying family
illnesses)
– Review of systems (subjective)
– Patient profile
Genogram
• Used to record history of family members
• Includes: age, cause of death or if living; their current health status
• Subjective data - what the patient tells you
• Objective data- perceptible to other persons; able to be analyzed, counted or
measured.
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Physical Examination – (Objective)
• A complete physical examination includes:
– Skin– Head & neck
– Thorax and lungs
– *Breasts
– Cardiovascular
– *Rectum
– *Genitalia
– Neurological system
– Musculoskeletal system
*may be deferred depending on reason for admission
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PE is done after the health history is obtained,
wash your hands before and after the exam
– Provide a well lighted, and warm area
warm your stethoscope in your hand
– Have pt. change into a gown if not already in so
– Respect the pts. Privacy at all times. Close doors, pull curtains, keep body
parts covered. Be aware of the other people that may be in the room (pt
roommate, family members, ancillary staff, etc.)
– Explain what you are going to do before you do it.
– Wear gloves when you may be exposed to blood and body fluids
– Use a organized and systematic approach to encourage cooperation and
trust
** A complete exam is not done on q.d. on every pt. in the hospital for
extended periods.
**Proficiency at physical exams requires repetition and reinforcement in the
hospital setting.
Physical exam (cont.’)
• Basic tools for physical exams requires use of your senses of vision,
hearing, smell as well as special tools :
– Stethoscope
– Bp cuff
– Tongue blade
– Flashlight
– Reflex hammer
– Pulse oximetry
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4 Approaches used in obtaining a Physical Assessment
Inspection
Auscultation
Percussion
Palpation
Inspection- observation/ general inspection
• Old, young, do they appear to be the stated age?
• Are they thin, obese, anxious, depressed?
- Posture- the posture that a pt. assumes may be indicative of illness. Posture
and stature are usually addressed on admission.
- Pts. With breathing difficulties may prefer to sit or they may lie perfectly still if
having abdomen pain.
- The pt. may prefer to pace if anxious or having renal colic
- Patients with meningitis may c/o head and neck pain upon flexing the neck
- Body movements- Tremors may be due to Parkinson’s or other causes.
- Asymmetrical movements may occur as a result of CNS disorders or CVA.
There may be drooping of one side of the face, weakness or paralysis of one
extremity or foot dragging.
- Spasticity may be present in Multiple Sclerosis. or dystonia in Parkinson’s
- Nutrition- obesity may be generalized or specifically localized in the trunk in
those with endocrine disorders (Cushing’s syndrome), have they been taking
corticosteroids for an extended period of time?
- Weight loss may be due to inadequate calorie intake over a long period of
time; or in diseases that produce muscle wasting (like in disorders that affect
protein synthesis – bulimia, liver disease).
- Speech patterns- voice slurred due to CNS disorders or damage to the
cranial nerves. Recurrent damage to the laryngeal nerve will produce
hoarseness. Speech may be slurred, halting or interrupted as in Multiple
Sclerosis).
- Vital signs- must be recorded as part of any physical examination. Values
that deviate from norms are reported to the physician. The fifth v.s. is also
evaluated and documented. Temperatures may vary slightly from one
individual to another. Some are normal at 98 while others are normal at 99.
temperatures vary slightly with the time of day (lowest in the morning, rising
1-2 degrees during the day hen dropping back down at night).
– Need to know that 37°C is the same as 98.6°F
Auscultation- examination by listening
Breathsounds, heart sounds, bowel sounds. Fetal tones
• Useful in estimating airflow through the lungs & detecting obstruction,
identifying heart sounds, and assessing bowel motility.
• Sounds from bed clothes, paper, hair on the chest, may cause
confusion while listening.
Percussion- examination by tapping
• Tympany- tapping over air filled stomach
• hyperresonance- inflated lung tissue (emphysema)
• Resonance- air filled lungs (percussion of a hollow organ like the lungs)
• Dullness- liver (diminished resonance)
• Flatness- thigh (absences of resonance
• Involves hyperextending the middle finger and pressing/tapping its
interphalangeal joint firmly on the surface to be percussed.
• Avoid contact with any other part of the hand, this dampens the vibration.
• Tap with a quick, but relaxed wrist motion, strike the joint of the finger
with the right middle finger. Aim at the distal joint. You are trying to
transmit vibrations through the bones of the joint to the tissue below. Use
the tip of the finger, not the pad.
– Strike finger at a right angle to the joint. Withdraw the striking finger
quickly to avoid dampening the vibration that you have created. Use the
lightest percussion possible that will produce a clear note. Thump about
two times, then move on to another place.
Palpation- examination by touch
- It is used to assess many parts of the body that are not visible (superficial
blood vessels, lymph nodes, thyroid gland, organs of the abdomen, pelvis,
rectum)
- Remember, when palpating the abdomen, auscultate first to avoid altering
bowel sounds.
- Some sounds may also be palpated. Thrills cause a sensation (like a
purring cat). Also, some voice sounds may be palpated.
- Palpation - feeling for lumps, bumps, tenderness, (thyroid, lymph modes,
Buits/trils over vessels or dialysis vascular access devices,
INSPECTION
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Posture - the posture that a pt. assumes may be indicative of illness.
(abnormal gait, bent over, ) Posture and stature are usually addressed on
admission.
Pts. With breathing difficulties may prefer to sit or they may lie perfectly still if
having abdomen pain.
The pt. may prefer to pace if anxious or having renal colic
Patients with meningitis may c/o head and neck pain upon flexing the neck
Body movements - Tremors may be due to Parkinson’s or other causes.
Asymmetrical movements may occur as a result of CNS disorders or CVA.
• There may be drooping of one side of the face,
• weakness or paralysis of one extremity or foot dragging.
• Spasticity may be present in Multiple Sclerosis; or advance Parkinson’s with
dystonia
Nutrition- obesity may be generalized or specifically localized in the trunk in
those with endocrine disorders (Cushing’s syndrome), or those taking
corticosteroids for a extended period of time.
• Or perhaps they are having G.I dysfunctions or illnesse (diarrhea, vomiting,
megacolon, bowel obstruction, esophageal atresia)
• Weight loss may be due to inadequate calorie intake over a long period of
time or in diseases that produce muscle wasting as in disorders that affect
protein synthesis.
Speech patterns- may be slurred due to CNS disorders or damage to the
cranial nerves.
• Recurrent damage to the laryngeal nerve will produce hoarseness.
• Speech may be slurred, halting or interrupted in flow (as in Multiple
Sclerosis).
Vital signs- must be recorded as part of any physical examination. Values that
deviate from norms are reported to the physician. The 5th v.s. (pain) is also
evaluated and documented. Temperatures may vary slightly from one
individual to another. Some are normal at 98 while others are normal at 99.
temperatures vary slightly with the time of day (lowest in the morning, rising
1-2 degrees during the day hen dropping back down at night).
• Need to know that 37°C is the same as 98.6°F
Physical Examination
Infants & Children
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Consider the pt’s continuum of growth & development, as well as the age
range
Think about the different rates of growth of various systems of the body.
What are the normal and abnormal patterns of growth and development (i.e. a
Babinski response is abnormal beyond 2yrs.).
Pediatric Assessment
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The examination of the adolescent patient is essentially the same as the adult.
Develop your own method for examination that varies with the age, illness,
etc.
You may write the steps on index cards until you memorized the method.
Repetition will help you master the assessment without omissions.
Remember, pts. Do not usually need a complete assessment every day.
Denver Developmental Screening test (DDST)
• A standard for measuring the attainment of developmental milestones
throughout infancy and childhood.
• Designed to detect developmental delays in personal-social, fine motoradaptive, language, and gross motor dimensions from birth - 6 yrs.
• Useful in comparing the measurements of length, weight, and head
circumference with norms.
• DDST measurements are usually done at well child visit (or more frequently)
during the first two years.
• More frequent measurements are taken when a patient is not keeping up with
the growth parameters or begins to fall behind the expected patterns of
growth.
• Consider four developmental levels:
– Infancy (the first year)
– Early childhood (1-4 yrs.)
– Late childhood (5-12 yrs.)
– Adolescence (13-20 yrs.)
• Overview of the physical examination: (adults and Peds)
– General survey- posture, development, weight (must weigh
peds), grooming, odors, facial expressions, speech, level of
awareness, LOC
– Vital Signs - count pulse and resp. rate, measure BP,
temperature.
– Try to examine supine pts. from the right side of the bed, moving from
the feet to the left side as necessary.
– Skin - examine exposed areas first; lesions, inspect hair and nails
– Head- hair, scalp, skull, face
– Eyes- sclera, conjunctiva, pupillary reaction, position and alignment of the
eyes. Use an opthalmalscope to examine inner portion of the eye.
– Ears- outer ear, ear canal, eardrum, note any hearing difficulty (may use
an otoscope)
– Nose and sinus- palpate for tenderness, examine nasal mucosa, some
physicians use the otoscope for this also
– Mouth and oropharynx- inspect the lips, buccal mucosa, gums, teeth, roof
of mouth, tongue and pharynx
– Neck- palpate for cervical nodes, masses, (thyroid gland)
– Back- inspect and palpate the back, note any redness, lesions to the skin,
scars,etc.
– Posterior lungs/ chest- inspect, palpate, percuss the chest, listen to breath
sounds, identify additional sounds
– Breasts- examine a woman with her arms relaxed and elevated. Check
skin under breast. For both sexes examine for axillary nodes.
• Anterior thorax and lungs- inspect, palpate, and percuss chest, listen to the
lung sounds; note any additional sounds
• Cardiovascular- listen at the apex, and lower sternal border.
• Abdomen- (have pt. lie on supine), inspect, palpate, and percuss the
abdomen.
– Palpate lightly then deep.
– Listen for bowel sounds in all four quadrants
• Inguinal area- palpate femoral arteries and feel for inguinal nodes
• Legs- check for PVD, edema, Homan’s sign; check pulses: dorsalis pedis,
posterior tibialis
• Be sure to leave the room as it was
Pediatric Assessment techniques
• Temperature- done with electronic thermometers on forehead or ear.
– Less constant in infants and children.
– Rectal temps. usually 99 until 3rd year.
– 50% of children (to 18 mo.) have an average rectal temp of 100.
– Temperature may range by as much as 3 degrees during the day.
Pediatric Assessment techniques
• Pulse - infants & children have more sensitive pulse to the effects of exercise
% emotion
Birth – 140
1-2 yrs.-110
1- 6 mo. – 130
2 – 6 yrs.- 95
6 - 12 mo.- 115
10 – 14 yrs - 85
• Resp. rate- has a greater range and is more responsive to exercise and
emotion.
– Newborn- 30-80
– Early childhood- 20-40
– Late childhood- 15-25
– Reaching adult levels by age 15
Observe respirations for longer than the usual 30-60 secs.
In infancy and early childhood, diaphragmatic breathing is predominant
In older children observe for chest movement by placing hand on chest to feel the
movement.
Pediatric Assessment techniques
• Blood pressure – levels gradually increases throughout infancy and
childhood.
– 1 mo. – 60 mm Hg
– 6 mo. – 70 mmHg
– 1 yr. – 95 mmHg
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6 yrs. – 100 mmHg
10 yrs. - 110 mmHg
16 yrs. – 120 mmHg
BP is not usually done on a child < 4 yrs.
Height - place infant on supine on a measuring board.
Weight – infant scale vs. standup
Head circumference - done during first two years
Skin – do no early and late childhood
Abdomen – most children and adolescents will exhibit a protuberant abdomen
•Palpate all quadrants of the abdomen. Children are ticklish
•Watch for changes in facial expression and the sound of the cry.
When examining the throat, note size and appearance of tonsils.
Musculo-Skeletal - observe the child walking, and movements while in bed
Nutritional Assessment
•What
are they eating? Regular diet vs. special diet?
What type of infant formula? Are they nursing? How well are they
tolerating food?
How many meals/ snacks do they eat a day?
• Allergies – what kind of reaction do they present?
• Drink alcoholic beverages? How much sweet drinks do children drink?
•Drinking plenty of fluids? How much?
•Does it correlate with urine output?
•Diarrhea or constipation? How many bowel movements do they normally
have a day?
•Have they ever been consulted by a nutritionist? For what?
•Ht. and Wt? BMI
•Teenagers go on fad diets and junk food binges. Eating disorders?
•Anorexia or bulimia
•Pica (ice, dirt cravings)
• Who cooks at home? Where do they buy groceries? Do they require inhome assistance and some one to cook?
•What condition are their teeth in? Do children have their teeth developed
aged appropriately? Do dentures fit well?
•Condition of the mouth? Sores, S/P surgery, etc. that hinders eating.
•Consult the dietician.
•Physical conditions and illnesses
•Burns
•Wounds
•Renal disease, liver disease, diabetes, cardiac disease
•GI diseases - N/V, Celiac disease, esophageal atresia, megacolon,
parasites
GI disturbances & obstructions
• Metabolic disorders
• Deformities: cleft palate
Laboratory results: Chem panel, CBC, cholesterols
• Anemia – low iron
• Low albumin, low protein
• high lipids
•lAmylase and bile levels indicating gall bladder
•infections