Health History and Physical Assessment
Lecture 1
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
Health History
Physical Assessment
• Subjective database
• Objective database
• Obtained through interview
• Obtained by observation and
physical assessment techniques
• Use of effective communications
skills
• Completes the client’s health
picture
Historical information often comes from a variety of
sources, including
• The patient
• The family
• Friends
• Other observers
Complete Health History
• Biographical data
• Chief complain
• History of Present Illness
• Past Health history
• Family History
• Functional Assessment ( Activities of Daily Living): Diet,
sleeping, exercise, coffee, alcohol, drugs, tobacco
Biographical Data
• Name:
• Age:
• Gender:
• Marital status:
• Occupation:
Complete Health History-Cont.
• Chief complain: 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
Analysis of the Symptom
• What
What makes symptoms better/worse?
• Describe
What does pain feel like?
• Where
Where & where does pain go?
• How
On Scale of 1-10 (other scales)
• When
When, How often, How long?
Past Health history
• Major childhood & adult illnesses
• Accidents and Injuries
• Hospitalizations and Operations
• Immunizations & dates: reactions to immunizations
• Surgery: Dates, Complications
• Medications: Current, past
• Allergies: Medications, environmental, food.
• Transfusions: Reactions, date & # of units if known
• Emotional status: Mood disorders, psychiatric attention
Family History
• Any family members with illness
• Age of parents: Age & cause of death if deceased
• Age & number of siblings: Health Status
• History of chronic diseases (ex: Hx of heart disease, hypertension,
cancer, TB, diabetes, asthma, STD's, kidney, thyroid disease)
• Major genetic disorders & health problems
Father died at age 43 in train accident. Mother died at age 67 of stroke; had varicose veins,
headaches One sister, died in infancy of unknown cause. Husband died at age 54 of heart attack
Daughter, 33, with migraine headaches, otherwise well; son, 31, with Headaches
Review of Systems
• Inquires about signs and symptoms as well as diseases related to
each body system
Physical assessment
Physical Assessment
• Usually performed after the health history
• Examiner must wash hands
• Make the patient comfortable
• Assessment must be systematic and organized
• Head – to - Toe Assessment
Assessment techniques
• Inspection
• Palpation
• Percussion
• Auscultation
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
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
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
Assessment techniques - Cont.
Percussion
• Technique that translates the
application of physical force into
sound
• Assess underlying structures for
location, size, density of
underlying tissue.
Percussion Technique
Percussion Sounds
Assessment techniques - Cont.
Auscultation
• Listening to sounds produced by the
body
• Instrument: stethoscope (to skin)
• Diaphragm –high pitched
sounds
Heart
Lungs
Abdomen
• Bell – low pitched sounds
Blood vessels
Nutritional Assessment
• BMI
• Dietary data
– Food record
– 24-hour recall
– Diet diary
• Conducting the Dietary Interview
• Cultural and religious considerations
Clinical Assessment
Indicators of Nutritional Status
• General appearance
• Skin, hair, and nails
• Mouth; includes teeth and gums
• Neck; includes thyroid
• Musculoskeletal
• Abdomen
• Nervous system
• Height and weight