Assessment: History and Physical Assessment

Question 1

the purpose of health assessment

Answer 1

Purpose: Allows the nurse to obtain descriptions about the patient’s symptoms, how the symptoms developed, and a process to discover any associated physical findings that will aid in the development of differential diagnoses

Question 2

types of health assessment

Answer 2

Comprehensive or complete health assessment

Interval or abbreviated assessment

A problem - focused assessment

An assessment for special populations

Question 3

Comprehensive or complete health assessment

Answer 3

Begins with obtaining a thorough health history and physical exam

Performed in acute care settings upon admission, once patient is stable, or when a new patient presents to an outpatient clinic

Question 4

Interval or abbreviated assessment

Answer 4

Performed at subsequent visits in an outpatient setting, if a patient has been under your care for some time,

Usually performed at a change of shift, when returning from tests, or upon transfer to your unit to another in-house unit

Allows you to thoroughly assess your patient in a shorter period of time

Question 5

A problem - focused assessment

Answer 5

Indicated after a comprehensive assessment has identified a potential health problem

Indicated when an interval assessment shows a change in status from the most current previous assessment or report you received, when a new symptom emerges, or the patient develops any distress

Directs the nurse to ask about symptoms and move quickly to a conducting a focused physical exam

Question 6

An assessment for special populations

Answer 6

Includes pregnant patients, infants, children, and the elderly

Question 7

Differentiate Subjective and Objective data

Answer 7

Subjective data includes factors that are reported by the patient

Objective data includes factors that are observable and measurable

Question 8

Describe the different components of a health history

Answer 8

Chief complaint

Present health status

Past health history

Current lifestyle

Psychosocial status

Family history

Review of systems and physical exam

Question 9

Chief complaint

Answer 9

may be elicited by asking one of the following questions:

So tell me why you have come here today?

Tell me what is your biggest complaint right now?

What is bothering you the most right now?

If we could fix any of your health problems right now, what would it be?

What is giving you the most problems right now?

***And if the patient has more than one complaint, discuss which one is the most troublesome for them and document the complaints in order of importance (determined by pt)

Question 10

Present health status

Answer 10

obtaining info about pt present health status allows the nurse to investigate current complaints

The mnemonic PQRST utilizes a structured format for information gathering, including evaluation of pain, and provides an efficient methodology to communicate with other providers

Question 11

P = Provocative or Palliative

Answer 11

what makes the symptoms better or worse?

Question 12

Q = quality

Answer 12

describe the symptoms

Question 13

R = Region or Radiation

Answer 13

Where in the body does the symptom occur? Is there radiation or extension of the symptoms to another area of the body?

Question 14

S = Severity

Answer 14

On a scale of 1-10 (10 being the worst) how bad is the symptom(s)? Another visual scale may be appropriate for patients that are unable to identify with this scale.

Question 15

T = Timing

Answer 15

Does it occur in association with something else (ex: eating, exertion, movement)?

Question 16

Past health history

Answer 16

Should elicit information about the pt childhood illnesses and immunizations, accidents or traumatic injuries, hospitalizations, surgeries, psychiatric or mental illnesses, allergies, and chronic illnesses

For women: include history of menstrual cycle, how many pregnancies and how many births

Question 17

Current lifestyle

Answer 17

Patients’ personal habits such as smoking or drinking, nutrition, cholesterol, etc.

Question 18

Psychosocial status

Answer 18

Emotional well being

Question 19

Family history

Answer 19

Important for identifying patient risk for certain disease states

Applicable generations with women to explore health status include grandparents, parents, and the children of your patient

Chronic illnesses or known diseases with genetic components should also be screened for;

Ex: cancer, diabetes, autoimmune disorders, cholesterol, heart disease, hypertension

Question 20

Review of systems and physical exam

Answer 20

the key to assessment is to ensure a consistent, methodical approach to avoid missing any vital assessment areas.

Question 21

physical exam

Answer 21

can be performed in a “head-to-toe” fashion, starting with the head and ending with the toes

Question 22

Prepare the patient for a health assessment

Answer 22

Explain the first part of the assessment will involve questions about the patient’s health concern, health habits, and lifestyle and that the information will only be shared with the patient’s other health care providers.

Inform the patient that after the health history is completed, body structures will be examined. Answer the patient’s questions directly and honestly.

Question 23

Prepare the environment for a health assessment

Answer 23

Provide a quiet, private space for assessment. Prepare the examination room before the health assessment is conducted by preparing the examination table, providing a gown and drape for the patient, and gathering instruments and special supplies needed for the assessment.

In a hospital or community-based facility, the room should be warm enough to prevent chilling, and the room should be adequately lit.

Question 24

Inspection

Answer 24

look for conditions that you can observe with your eyes, ears, nose

Skin color, location of lesions, bruises or rash, symmetry, size of body parts and abnormal findings, sounds, and odors

Should ALWAYS occur FIRST during an assessment

Most frequently used technique

Question 25

Auscultation

Answer 25

Performed following inspection, especially with abdominal assessment

Abdomen should be auscultated before percussion or palpation to prevent production of false bowel sounds

Ensure exam room is quiet

Done over bare skin, listen for one sound at a time

Can’t do over clothing as it can produce false sounds or diminish true sounds

Question 26

Palpation

Answer 26

requires you to touch pt with different parts of your hand using different strength pressures

During light palpation, you press the skin about ½ inch to ¾ inch with the pads of your fingers.
allows you to assess for texture, tenderness, temperature, moisture, pulsations, and masses.

When using deep palpation, use your finger pads and compress the skin approximately 1½ inches to 2 inches - performed to assess for masses and internal organs

Question 27

Percussion

Answer 27

used to elicit tenderness or sounds that may provide clues to underlying problems

Press the distal part of the middle finger of your non dominant hand firmly on the body part

Keep the rest of your hand off the body surface

Flex the wrist, of your dominant hand, using the middle finger of your dominant hand, tap quickly and directly over the point where your other middle finger contacts the patient’s skin, keeping the fingers perpendicular; listen