History.Percuss.330.Fall.09
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Transcript of History.Percuss.330.Fall.09
Health History Interview
Nursing 330
Shirley Comer
History and Physical – Overview of The Classic Format
Biographical Info Chief Complaint – Reason for seeking Treatment History of the Present Illness – (Current Health Status) Past Health History Family History Psychosocial Profile Review of Systems Summary of Findings Physical Assessment
– Findings and Plan for treatment
Biographical and Chief Complaint
Biographical Data– Name, address, phone#, Sex, marital status, race,
ethnic origin, occupation, religion, dependants, education level, Insurance, advanced directives
Source of Information– From pt or family or other
Chief Complaint– Why did pt seek services- In pt own words & in
quotes
History of Present Illness
Elaborates on the Chief Complaint– Onset, Duration & severity
Pain rating if warranted
– Symptoms– Precipitating, Alleviating or aggravating factors– Home treatments– Any medical treatments– Why seeking treatment now
Past History
Childhood Illnesses– Measles, Chicken Pox, Mumps ect
Accidents or Injuries– Dates and causes
Hospitalizations and operations (get dates) Major Health Conditions
– Dates, current state of condition Immunizations- including flu, pneumonia, Hep B, gardisil, &
tetanus vaccines Allergies
– Environmental, food and medication– Describe reaction
Health History (cont)
List of current medications – include doses and times – OTC meds – Health food supplements– Complimentary or alternative medicine
treatments
Recent Travel/Military Service
Family History
Age and health or cause of death of each immediate blood relative, including grandparents
Age and health or cause of death of each natural child
Genogram
Genogram pix
Psychosocial Assessment
Heath care practices and beliefs Typical day 24 hour diet recall Spiritual assessment
– Religion if any– Is a Chaplin needed– Special practices of religion
Blood transfusions Abortion Surgery Dietary concerns
Psychosocial Assessment cont
Assess activities of daily living Assess self care abilities
– Self-Esteem Education, financial, values, religious practices
– Activity Amount and ability to perform
– Sleep Patterns and use of aids, naps
Psychosocial Assessment cont
– Interpersonal relationships Support systems
– Coping Perceptions of stress, major life changes
– Personal habits Can they care for themselves
– Drugs, ETOH, Tobacco use– Environmental Hazards
Throw rugs, inadequate heat, water– Occupational
Hazards of work place
Review of Systems
General health status sexual Skin nose lungs MS Hair sinuses CV Neuro Nails mouth PV Hemo Head throat GI Endocrine Eyes Neck GU Ears Axilla Genital
Example of Subjective Write up of Review Of Systems
Skin Hair and Nails:– Pt denies psoriasis, itching, rashes, scars, sores,
ulcers, and warts. Reports mole on left cheek that has been present and unchanged since early childhood. Pt reports no changes in hair textures, or reaction to hot and cold. Denies hair loss or changes to nails. Reports longitudinal ridges have been present in nails since childhood. Pt reports she colors her hair every 6 weeks at a salon and shampoos her hair daily.
Example of Objective information write up
Skin, Hair and Nails:– Uniform skin color with slightly darker exposed
areas. No jaundice, cyanosis, pallor or erythema. Mucus membranes and conjunctiva pink. No unusual odors. Hair evenly distributed, no alopecia. Nails well groomed and convex. No clubbing noted.
Getting Started
Choose comfortable room Provide privacy Reduce noise, distractions Sit 4 to 5 feet from pt. Avoid standing Remain at pt’s level Introduce your self and explain procedure Don’t use first name unless invited to
Strategies in Interviewing
Use open ended questions to invite elaboration.– “Tell me about your cancer treatment”
Use closed ended questions to inhibit elaboration or refine answer.– “Did you have Chemotherapy.”
Strategies cont
Facilitation- encourage pt to continue– “uh-Huh”, “go on”, “yes”
Silence- Allows interviewer and pt to gather thoughts
Reflection- Focuses on last topic– “You said your head hurts after dinner”
Empathy- Allows pt to express feelings– “This must be very hard for you”
Strategies cont
Clarification- clears up confusion– “What do you mean by tired blood”
Confrontation- Allows interviewer to focus on topic not brought up by pt
– “You say your arm doesn’t hurt but you’re not moving it”
Interpretation- allows interviewer to link topics– “ It seems that you get a headache after every vacation”
Explanation- Teach Summary- Condenses all information
Ten Traps of Interviewing
1. Providing false reassurance– “I’m sure you’re going to be OK”
2. Giving unwanted advise– “If I were you I’d ________”
3. Using authority– “Your Doctor knows best”
4. Using avoidance Language- using euphemisms– “Passed on, I’ve got sugar ect”
Traps cont
5. Distancing- impersonal speech– “the left breast has a lump”
6. Using Professional jargon– “When did you void last”
7. Using leading or biased questions– “You don’t smoke, do you?”
Traps cont
8. Talking too much– prevents pt from focusing on task
9. Interrupting– let pt finish own sentences– Don’t share personal info
10. Asking “why” questions- implies blame– “Why would you go near an x-ray machine if you’re
pregnant”
Tools of Physical Assessment
Introduction to assessment techniques
Classic sequence used during physical assessment– Inspection – observation– Percussion – assessing underlying
structures by taping technique– Palpation – touch– Auscultation – listening with stethoscope
Assessment Techniques (cont)
All physical assessments should follow this structure
Only exception is in the abdomen– Auscultation done before palpation and
percussion to avoid stimulating bowel sounds
Note that auscultation is done last.
Inspection
Uses sense of sight, hearing and smell to assess pt
Palpation
Uses sense of touch Allows assessment
surface texture, consistency, temperature, symmetry
Pulsations, rigidity, chest excursion
Percussion technique
Lightly place only the middle finger of your nondominant hand on the surface to be percussed
Quickly strike with the pad of the middle finger of your dominate hand
Assess the quality of the sound– Dull = underlying solid tissue– Resonant/tympanic = air
filled space
Auscultation
Uses stethoscope to assess sound
Breath sounds, bowel sounds, murmurs, bruits, egophony ect..
The Stethoscope pix