HEALTH ASSESSMENT & PHYSICAL ASSESSMENTIntroductionThe health assessment and physical examination are the first steps toward providing safe and competent nursing care.The nurse is in a unique position to determine each patient’s current health status, distinguish variations from the norm, and recognize improvements or deterioration in his or her condition.As a nurse, you must be able to recognize and interpret each patient’s behavioral and physical presentation. By performing health assessments and physical examinations, you will identify health patterns and evaluate each patient’s response to treatments and therapies.

DefinitionHealthHealth is a state of complete physical, mental, social well being and not merely the absence of disease or infirmity.

assessmentaccording to ANA Asessment is defined as a systematic, dynamic process by which the nurse through interaction with client, significant others & health care providers, collects & analyzes data about client.

Purpose of health assessment1. To collect data about physical, mental, & social well-being of client2. To identify the problem in early stage3. To determine the cause & extent of disease4. To evaluate/monitor the changes in client’s health status5. To determine the nature of treatment required for client6. To alleviate the complications7. To certify whether client is medically fit to resume duties8. To contribute in medical research9. To collect data systematically

10. To identify clients strength, weakness, knowledge, motivation, support system & coping abilities

HEALTH HISTORYThe purpose of the health history is to collect Subjective data – what the person says about himself or herself.Objective data – physical examination, laboratory studies to form the data base.The data base is used to make a judgement or a diagnosis about the health status of the individual.

Health history provides a complete picture of the person past & present health. It describes the individual as a whole& how the person interacts with the environment.

Factors affecting the collection of history1. Physical setting/environment2. Client’s personality & behavior3. Communication skill4. Problem5. Nurses personality & behavior

6. Nurses knowledge & skill

Although history forms vary, most contain information in this sequence of categories:

1. Biographical data2. Chief complaints3. Present health or history of present illness4. Past history5. Family history6. Review of systems7. Functional assessment of activities of daily living (ADLs)

Biographic dataName, address & phone number, age & birth date, birth place, gender, marital status, race, ethnic origin, occupation, usual & present.The person’s primary language & authorized representative, should be recorded here. This is in response to research showing differences in language & culture may have an impact on the quality & safety of care.

Source of history1. Record who furnishes the information – usually the person by themselves.

Although the source may be a relative or friend2. Judge how reliable the informant seems & how willing he or she is to communicate. 3. Note any special circumstances, such as the use of an interpreter. Sample

statements include:Patient himself, who seems reliablePatient’s son, who seems reliableMrs. X, interpreter for R who does not speak English

Chief complaintsthis is a brief spontaneous statement in the person’s own words that describes the reason for the visit. It states one (possibly two) symptoms or signs & their duration. A symptom is a subjective sensation that the person feels from the disorder.A sign is an objective abnormality that the examiner could detect on physical examination or in laboratory reports.

Present health or history of present illnessIt is the chronological record of the reason for seeking care, from the time the symptom first started until now.As the client talks, do not jump to conclusions & bias the story by adding opinions.Te final summary of any symptom the person has should include the 8 critical characteristics

1. LocationBe specific; ask the client to point the location. If the problem is pain, note the precise site. “head pain” is vague, whereas, descriptions such as “pain behind the eyes”, “jaw pain & occipital painare more precise & are diagnostically significant. Is the pain localized to this site or radiating? Is the pain superficial or deep?

2. Character or quality

It includes terms like buring, sharp, dull, aching, gnawing, throbbing, shooting, viselike. Use similes- does blood in the stool look like sticky tar? Does bloof in vomitus look like coffee grounds?

3. Quantity or severityAttempt to quantify the sign or symptom such as “profuse menstrual flow soaking five pads per hour”, the symptom of pain is difficult to quantify because of individual perception. With pain, avoid adjectives & how it affects daily activities.

4. Timing(onset, duration, frequency). When did the symptom first appear? Give the specific date & time, or state specifically how long ago the symptom started prior to arrival (PTA).

5. SettingWhere was the person or what was the person doing when the symptom started? What brings it on? For example: did you notice the chest pain after shoveling snow, or did the pain start by itself?

6. Aggravating or relieving factorsWhat makes the pain worse? Is it aggravated by weather, activity, food, medication, standing bent over, fatigue, time of day, season, & so on? What relieves (E.g. rest, medication, or ice pack)? What is the effect of any treatment? Ask, “what have you tried? Or “what seems t help?”.

7. Associated factorsIs this primary symptom associated with any others (e.g., urinary frequency & burning associated with fever & chills)? Review the body system related to this symptom now rather than wait for the review of systems.

8. Patient’s perceptionFind out the meaning of the symptom by asking how it affects daily activities. Also ask directly. ”what do you think it means?” this is crucial because it alerts you to potential anxiety if the person thinks the symptom may be omnius.

The question sequence could be arranged in PQRSTP: Provocative or PalliativeWhat brings it on? What were you first noticed it? What makes it better? Worse?

Q: Quality or QuantityHow does it look, feel, sound? How intense/severe is it?

R: Region or RadiationWhere is it? Does it spread anywhere.

S: Severity ScaleHow bad is it (on scale of 1 to 10)? Is it getting better, worse, staying the same?

T: TimingOnset – exactly when did it first occur?

Duration-how long did it last? Frequency-how often does it occur?

U: Understand Patient’s PerceptionUnderstand patients perception of the problem. What do you think it means?

Past health Past health events may have residual effects on the current health state. Childhood illnessMeasles, mumps, rubella, chicken pox, pertusis, & strep throat. Avoid recording “usual childhood illness,” because an illness common in the person’s childhood (e.g., measles) may be unusual today. Ask about serious illnesses that may have sequelae for the person in later years (e.g., rheumatic fever, scarlet fever, & poliomyelitis).

Accidents or injuriesAuto accidents, fractures, penetrating wounds, head injuries (especially if associated with unconsciousness) & burns.

Serious or chronic illnessesDiabetes, hypertension, heart disease, sickle-cell anemia, cancer, & seizure disorder.

HospitalizationCause, name of the surgeon, name of hospital, & how the person recovered.

OperationsType of surgery, date , name of the surgeon, name of hospital, & how the person recovered.

Obstetric historyNo.of pregnancies (gravidity), no.of deliveries in which the fetus reached full term, no.of preterm pregnancies (preterm), no.of incomplete pregnancies (abortions), & no.of children living.For any incomplete pregnancies, record the duration & whether the pregnancy resulted in spontaneous (S) or induced (I) abortion.

ImmunizationMeasles-mumps-rubella, polio, diphtheria-pertussis-tetanus, hepatitis B, human papiloma virus, haemophilus influenza type b, pneumococcal vaccine.

Last examination datePhysical, dental, vision, hearing, electrocardiogram, chest x-ray examinations

AllergiesNote both the allergen (medication, food, or contact agent, such as fabric or environmental agent) & the raction (rash, itching, runny nose, watery eyes, difficulty breathing). With a drug, this symptom should not be a side effect but a true allergic reaction.

Current medications

Note all prescription & over-the-counter medications. Ask specifically about vitamins, birth control pills, aspirin, & antacids, because many people do not consider these to be medications.

FamilyhistoryAsk about the age & health or the age & cause of death of blood relatives, such as parents, grand parents, & siblings. Specifically ask for any family history of heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, sickle-cell anemia, arthritis, allergies, obesity, alcoholism, mental illness, seizure disorder, kidney disease, & tuberculosis. Construct an accurate family tree or genogram.

NORMAL RANGE OF FINDINGS ABNORMAL FINDINGSAPPEARANCEPosture: Posture is erect & position is relaxed

Sitting on edge of chair or curled in bed, tense muscles, frowning, darting watchful eyes, rstless pacing occur with anxiety & with hyperthyroidism. Siting slumped in chair, slow walk, dragging that occur with depression & some organic brain diseases.

Body movements: Body movements are voluntary, deliberate, coordinated, & smooth & even.

Restless, fidgety movements, or hyperkinetic appearance occur with anxiety.Apathy & psychomotor slowing occur with depression & organic brain disease.Abnormal posturing & bizarre gestures occur with schizophrenia.Facial grimaces

Dress. Dress is appropriate for setting, season, age, gender, & social group. Clothing fits & is put on appropriately

Inappropriate dress can occur with organic brain syndromeEccentric dress combination & bizarre make-up with schizophrenia or manic syndrome

Grooming & hygiene.The person is clean groomed; hair is neat & clean; women have moderate or no make-up; men are shaved or beard or mustache are well groomed. Nails are clean.

Unilateral neglect occurs following some cerebrovascular accidents.Inappropriate dress, poor hygiene, & lack of concern with appearance occur with depression & severe Alzheimer’s disease.

BEHAVIORLevel of consciousness.The person is awake, alert, aware of stimuli from the environment & within the self, & responds appropriately to stimuli.

Lethargic, obtunded, stupor or semi coma, coma.Acute confusional state

Facial expression.The look is appropriate to the situation & changes appropriately with the topic.

Flat, mashlike expression occurs with parkinsonism & depression

SpeechJudge the quality of speech by noting that the person makes laryngeal sounds effortlessly & shares conversation appropriately.

Dysphonia is abnormal volume, pitch

Mood & effectJudge this by body language & facial expression COGNITIVE FUNCTIONSOrientation.Time: day of week, date, year, seasonPlace: where person lives, present location, type of building, name of cityPerson: own name, age, who examiner is, type of worker

Disorientation occurs with organic brain disorders, such as delirium & dementia

Attention SpanCheck the person’s ability to concentrate by noting whether he or she completes a thought without wanderingRecent memoryAssess recent memory in the context of the interview by the 24-hour diet recall or by asking the time the person arrived at the agencyRemote memoryIn the context of the interview, ask the person verifiable past eventsNew learning-The four unrelated words testThus tests the person’s ability to lay down new memories. It is a highly sensitive & valid memory test. It also avoids the danger of unverifiable materialPick four words with semantic & phonetic diversityBrown funHonesty carrotTulip ankleEyedropper loyalityAfter 5 minutes, ask for the recall of the four words, to test the duration of memory, ask for a recall at 10 minutes & 30 minutes.

PHYSICAL EXAMINATION

A physical examination is conducted as an initial evaluation in triage for emergency care; for routine screening to promote wellness behaviors and preventive health care measures;

The physical examination requires that the examiner develop technical skills & a knowledge base. The skills requisite for the physical examination are inspection, palpation, percussion, auscultation.

Inspection

Inspection is concentrated watching. It is close, careful scrutiny, first of the individuala as a whole & then of each body system. Inspection always comes first. A focused inspection takes time & yields a surprising amount of data.Inspection requires good lighting, adequate exposure, occasional use of certain instruments (otoscope, ophthalmoscope, penlight, nasal & vaginal specula).

PalpationPalpation follows & often confirms points noted during inspection. Palpation applies sense of touch to assess these factors: texture, temperature, moisture, organ location & size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, & presence of tenderness or pain.

Different parts of the hands arebest suited for assessing different factors: Fingertips-best for fine tactile discrimination, as of skin texture, swelling, pulsation,

& determining presence of lumps. A grasping action of the fingers & thumb-to detect the position, shape, &

consistency of an organ or mass The dorsa (backs) of hands & fingers-best for determining temperature because

the skin here is thinner than on the palms. Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand-best for

vibration.Palpation technique should be slow & systematic. Starting with light palpation & then deep palpation.

PercussionPercussion is tapping the person’s skin with short, sharp strokes to assess underlying structures. The strokes yield a palpable vibration & a characteristic sound that depicts the location, size & density of the underlying organ.Percussion has the following uses

Mapping out the location & size of an organ by exploring where the percussion note changes between the borders of an organ & itsneighbours

Signaling the density (air, fluid, or solid) of a structure by a characteristic note Detecting an abnormal mass if it is fairly superficial; the percussion vibrations

penetrate about 5 cm deep-a deeper mass would give no change in percussion Eliciting pain if the underlying structure is inflamed, as with sinus areas or over the

kidney Eliciting a deep tendon reflex using the percussion hammer.

Two methods of percussion can be used-direct (immediate) & indirect(mediate) In direct percussion the striking hand directly contacts the wall In indirect percussion is used more often & involves both handsIndirect percussion is used more often & involves both hands. The striking hand contacts the stationary hand fixed on the person’s skin.

Production of sound1. Amplitude or intensity

A loud or soft sound, the louder the sound, the greater the amplitude. Loudness depends on the force of the blow & the structure’s ability to vibrate

2. Pitch or frequency

The no.of vibrations per second, written as ‘cps’ or cycle per second. More rapid vibrations produce a high pitched tone; slower vibrations yield a low-pitched tone

3. Quality or timbreA subjective difference due to sound’s distinctive overtones. A pure tone is a sound of one frequency.

4. DurationThe length of time the note lingers.

Amplitude

Pitch Quality Duration Sample location

Resonant Medium-loud

Low Clear, hollow Moderate Over normal lung tissue

Hyper resonant

Louder Lower

Booming Longer Normal over child’s lung Abnormal in the adult, over lungs with increased amount of air, as in emphysema

Tympany Loud High Musical & drumlike

Sustained longest

Over air-filled viscusEg., the stomach, the intestine

Dull Soft High Muffled thud Short Relatively dense organ, as liver or spleen

Flat Very soft High A dead stop of sound, absolute dullness

Very short

When no air is present, over thigh muscles, bone, or over tumor

AuscultationAuscultation is listening to sounds produced by the body, such as the heart & blood vessels & the lungs & abdomen. Certain body sounds with ear alone for example, the harsh gurgling of very congested breathing. However, most body sounds are very soft & must be channeled through a stethoscope to evaluate.

SettingThe examination room should be warm & comfortable, quite, private, & well lit.

1. Time of examining must be convenient to both client as well as nurse, and examination should not be done in a hurry

2. Adequate light – for visualization of body area3. Equipment-before starting examination all the equipment needed must ne in reach

& in working condition. Client must be relaxed & sit in comfortably on table/chair4. Privacy: as patient feels emabarassed on exposing there body privacy is a must5. Temperature- a warm environment / room temperature should be provided. It

should neither be too hot/ too cold6. Positions7. Draping- means cover the adjacent body areas being exposed. Draping maintains

privacy as well as covering body avoids heat loss unnecessarily.

Equipment Platform scale with height attachment Skinfold calipers

Sphygmomanometer Stethoscope with bell & diaphragm endpieces Thermometer Pulse oximeter Flashlight or penlight Otosope/ophthalmoscope Tuning fork Nasal speculum Tongue depressor Pocket vision screener Skin-marking pen Flexible tape measure & ruler marked in centimeters Reflex hammer Sharp object Cotton balls Bivalve vaginal speculum Clean gloves Materials for cytologic study Lubricant Fecal occult blood test materials