Assessment: History and Physical Assessment Flashcards
the purpose of health assessment
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
types of health assessment
Comprehensive or complete health assessment
Interval or abbreviated assessment
A problem - focused assessment
An assessment for special populations
Comprehensive or complete health assessment
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
Interval or abbreviated assessment
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
A problem - focused assessment
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
An assessment for special populations
Includes pregnant patients, infants, children, and the elderly
Differentiate Subjective and Objective data
Subjective data includes factors that are reported by the patient
Objective data includes factors that are observable and measurable
Describe the different components of a health history
Chief complaint
Present health status
Past health history
Current lifestyle
Psychosocial status
Family history
Review of systems and physical exam
Chief complaint
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)
Present health status
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
P = Provocative or Palliative
what makes the symptoms better or worse?
Q = quality
describe the symptoms
R = Region or Radiation
Where in the body does the symptom occur? Is there radiation or extension of the symptoms to another area of the body?
S = Severity
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.
T = Timing
Does it occur in association with something else (ex: eating, exertion, movement)?
Past health history
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
Current lifestyle
Patients’ personal habits such as smoking or drinking, nutrition, cholesterol, etc.
Psychosocial status
Emotional well being
Family history
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
Review of systems and physical exam
the key to assessment is to ensure a consistent, methodical approach to avoid missing any vital assessment areas.
physical exam
can be performed in a “head-to-toe” fashion, starting with the head and ending with the toes
Prepare the patient for a health assessment
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.
Prepare the environment for a health assessment
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.
Inspection
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
Auscultation
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
Palpation
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
Percussion
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
