Health History Physical Assessment 2012[1]
Transcript of Health History Physical Assessment 2012[1]
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Health Assessment
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Health assessment contains health
history,
vital signs,
general surveyand
physical assessment
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Client and environment require special consideration
Keep the client informed
Be organizeddemonstrate respect for the clients apprehension
Appear calm, organized and competent at the bedside
Adjust environment according to the client
s need(special accommodations), quiet, warm and well lit
Gather equipment
Positioning and draping
Preparing
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Purpose of the Health History
Health history is a review of the clients functional health
patterns prior to the current contact with a health care agency,focuses on: functional health patterns, responses to changes in
health status, and alterations in lifestyle.
Used in developing the plan of care and formulating nursing
interventions.
HEALTH HISTORY
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Purpose of physical health examination is to evaluate thephysiologic outcomes of health care and thus the progress of aclients health problem
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Demographic info: name, address, date of birth, gender,
religion, race, ethnic origin, occupation, insurance
Reason for seeking health care: this should be put in thepatients own words, its pt actual report
Clients perception of health status: clients opinion of his/her
general health
Previous illnesses, hospitalizations, and surgeries
Subjective dataElements of health history
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Family history of acute or chronic illnesses that tend to be
familial
Immunizations, exposure to communicable disease
Allergies
Current medications
Psychosocial history
Value and belief system
Health history cont
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Sociocultural history
Activities of daily living
1. Nutrition
2. Elimination
3. Rest/sleep
4. Activity/exercise
Review of systems(ROS)-pain assessment
Health history cont
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Physical assessment
Height , weight, v/s, (general survey)
Physical exam can be head to toe exam, focused exam of a
body part, or body system
Conducted in an aseptic, systematic and efficient manner
Objective data
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General survey; clients physical appearance, mood and
behavior, signs and symptoms of distress
Document data in an organized format, use proper terminology
and agency-approved abbreviations
Physical assessment
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1. Inspection
2. Palpation
3. Percussion
4. Auscultation (see hand-out)
Techniques
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1. Integumentary system (hair, scalp, skin and nails)2. Head and Neck (skull, face, eyes, ears, nose,
mouth, pharynx, and neck)
3. Thorax and Lungs
4. Heart and Vascular system
5. Lymphatic system
6. Abdomen
7. Genitalia
8. Musculoskeletal system
9. Neurologic system
Systems
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Skin
Hair and Scalp
Nails
Skin assessment provides a noninvasive window toobserve the bodys physiological functions.
Integumentary system
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Color
Lesions
Moisture
Temperature
Texture
Mobility and Turgor
Edema
SKIN
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Thorax and Lungs
Landmarks for inspection, auscultation, and percussion
Anterior and posterior examination
Shape and symmetry
Thoracic expansion
HEART AND LUNGS
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Auscultation of Normal Breath Sounds
1. Vesicular sounds
2. Bronchovesicular sounds
3. Bronchial sounds
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Auscultation of Adventitious Breath Sounds
Crackles
Rhonchi
Wheezes
Pleural friction rub
Stridor
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Heart
Landmarks for inspection, palpation, auscultation
Heart sounds
Palpation for thrills and heaves
Abnormal auscultatory findings
Murmurs
Bruits
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Vascular System
Blood perfusion of peripheral vesselsPeripheral pulses compared bilaterally
Skin temperature, color
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Measurements
Capillary Refill: Push on the tip of the great toe or the nail bed until
blanching occurs. Then release and note how long it takes for the red color
to return, a reflection of blood inflow to the distal aspect of the lower
extremity. Longer then 2-3 seconds is considered abnormal and consistent
with arterial insufficiency.
Edema: There is a very subjective scale for rating edema which ranges
from "trace at the ankles" to "4+ to the level of the knees." After examining
many patients, you'll develop a sense of what is a lot and what is not.
Pulses: Theseare rated on a scale ranging from 0 (not palpable) to 2+(normal). As with edema, this is very subjective and it will take you a while
to develop a sense of relative values. In the event that the pulse is not
palpable, the doppler signal generated is also rated, ranging again from 0
to 2+.
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Inspection
Contour
Symmetry
Umbilicus
Surface motion
Scars
Abdomen
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Auscultation
All four quadrants in a systematic fashion
Beginning with the RLQ
Tympany
Dullness
BruitsHyperactive or hypoactive bowel sounds
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Light palpation in all four quadrants beginning with
the RLQ Resistance
Tenderness
Rebound tenderness
Organ enlargement
Abdomen
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Inspection
Palpation
Range of Motion (ROM)
Bilateral Comparison
Joints
Arthritis
Osteoarthritis
Crepitus
Musculoskeletal system
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Mental Status
Appearance
Level of alertnessSpeech
Behavior
Awareness of environment, also referred to as orientation
Mood
Affect: flat ,excitable, appropriate.
Thought ProcessThought Content
Memory
Judgment
Higher cortical functioning and reasoning
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WakefulnessUnresponsive, Sleepy, Drowsy, Awake, Alert
(Eye Opening None to spontaneous in Glascow Coma Scale)
Identifies person, place, time typically, but circumstances
may prevent those steps if medicated or unfamiliar with
environment
Confusion
Orientation
Memory defects of all kinds, intermittent or constant
(Delirium b/c illness or medication OR depression, or dementia)
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Observations for Documentation
Skin LesionsColor
Associated pain, redness, heat, swelling
Size and location
Pattern of eruption (macular, papular, scaling,
oozing, etc.)
Distribution (linear, circular, symmetric
Wounds Wound bedWound edges and margins
Wound size (in cm)
Surrounding skinCondition of dressing removed
Odor, exudate
Careful documentation of findings of all wounds
is essential for legally sensible practice