Transcript Lecture 1

Health History and Physical Assessment
Lecture 1
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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
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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
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Historical information often comes from a variety
of sources, including
• The patient
• The family
• Friends
• Other observers
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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
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Biographical Data
• Name:
• Age:
• Gender:
• Marital status:
• Occupation:
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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
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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?
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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
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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
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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
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Review of Systems
• Inquires about signs and symptoms as well as diseases
related to each body system
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Physical assessment
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Physical Assessment
• Usually performed after the health history
• Examiner must wash hands
• Make the patient comfortable
• Assessment must be systematic and organized
Assessment Sequencing
• Head – to - Toe Assessment
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Assessment techniques
• Inspection
• Palpation
• Percussion
• Auscultation
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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
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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
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Assessment techniques - Cont.
Percussion
• Technique that translates the
application of physical force into
sound
• Assess underlying structures for
location, size, density of
underlying tissue.
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Percussion Technique
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Percussion Sounds
Tympany
Gastric bubble
Hyperresonance
Emphysematous lung
Resonance
Healthy lung
Dullness
Liver
Flattness
Muscle
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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
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Nutritional Assessment
• BMI
• Dietary data
– Food record
– 24-hour recall
– Diet diary
• Conducting the Dietary Interview
• Cultural and religious considerations
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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
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