Physical Assessment: Health History

Front 1

Nurse Practitioner Approach

Back 1

• Medical and nursing diagnosis are independent but interrelated
o Med diag-etiology of disease and curing
o Nursing diag-impact of health on the individual and caring
• NP-collect date based on holistic model and biomedical model

Front 2

Expanding Assessment Factors

Back 2

Expanding Assessment Factors
• Growth and development
• Emotional Status
• Cultural,regligious, socioecon status
• Performance of activities of daily living
o toiliting, bathing, feeding, etc, your self
• Coping patterns
• Patient perception/satisfaction w their health status

Front 3

Problem-oriented Record Organization

Back 3

• S (subjective)-what the patient, family, or chart, tells you
• O (objective)-what you observe (exam and labs)
• A (assessment)-what you think is going on
o Ex) “46 year old female w/ hypertension and sub-optimal control”
• P (plan) –what you intend to do
• Interview= approx 20 min
• Examination= 5 min

Front 4

Signs and Symptoms

Back 4

• 2 types of data
o subjective data
• what the person says about him or herself during the history taking
• SYMPTOMS
o Objective data
• What the HCP observes by inspecting, percussing, palpitating and asculting during the physical exam and lab results
• SIGNS

Front 5

Subjective or Objective: deviated septum

Back 5

objective

Front 6

Subjective or Objective: indigestion

Back 6

subjective

Front 7

Subjective or Objective: corse hair

Back 7

objective

Front 8

Subjective or Objective: blurred vision

Back 8

subjective

Front 9

Subjective or Objective: intermittent cough

Back 9

subjective

Front 10

Subjective or Objective: intact gag reflex

Back 10

objective

Front 11

Subjective of Objective: sore shoulder

Back 11

subjective

Front 12

Subjective of Objective: orthopnea

Back 12

• need pillow in order to breathe
• →subjective

Front 13

Subjective of Objective: voice change

Back 13

subjective OR objective
primarily subjective

Front 14

Subjective of Objective: Non-tender abdomen

Back 14

objective

Front 15

Subjective of Objective: abdominal pain

Back 15

subjective

Front 16

Subjective of Objective: morning stiffness

Back 16

subjective

Front 17

Subjective of Objective: blood in urine

Back 17

• Subjective OR objective
o Can come in saying they saw blood in urine (subjective) but nurse can find blood through urine dip (objective)

Front 18

Why Learn Basic Clinical Skills of Physical Assessment?

Back 18

• Most diagnoses can be made based on history alone
• Even more likely after physical exam added
• Lab tests usually just confirm what was found during H&P

Front 19

Stages of Development

Back 19

• Newborn (birth)
• Infancy (0-12 months)
• Early childhood (1-4 years)
• Middle childhood (5-10 years)
• Adolescence (11-20 years)
o Early, middle, late

Front 20

4 Types of Data Collection

Back 20

1. Complete-Traditional H&P Data Base
• Comprehensive
• not really in hospital setting
2. Episodic Data Base
• more problem centered
• ex) come in w/ a new sore throat
3. Follow-up Data Base
• more problem centered
• Coming in to check management of problem
• ex) high cholesterol-coming in to see how it is doing
4. Emergency Data Base
• ABCs
o Airway, breathing, circulation

Front 21

Complete Data Base-H&P

Back 21

• Combination of subjective and objective information along with relevant diagnostic studies
• Others refer to your documentation→BE SPECIFIC
o Ex) at age 6 NOT 5 years ago

Front 22

The Interview

Back 22

• Introduction
o Greet people by name and introduce yourself
• Older people prefer last name
• Working phase
o Open-ended questions
• What brings you in today?
• Closed-ended questions
o Direct and quick
o Yes or no
• Try not to ask too many questions at once
o Break it down
o NOT “have you ever had w, x, y, or z?”
• “Classic H&P”
o physical assessment least important

Front 23

Classic History and Physical Order

Back 23

• Intro info
• CC-chief complaint
• HPI-history of present illness
• PMH-past medical history
• Current health history
• Social, occupational, family history
• Functional Assessment
• ROS-Review of Systems
• PE-physical examination

Front 24

Identifying Data in the History

Back 24

• First thing mentioned
• Initials only
• Name, age, etc

Front 25

Chief Complaint

Back 25

• Primary reason for patient seeking medical attention
• Stated in patients own words and written in quotation marks
• Not a diagnostic statement

Front 26

History of Present Illness

Back 26

• Well person→statement about general state of health
• Ill-account of chief complaint
o Analysis of a Symptom

Front 27

Analysis of Symptom

Back 27

Used for HPI-8 points

1. Location
2. Character or quality
• Ex) does the blood look like tar? Is it mixed w/ the stool or is it on top of the stool?
3. Quantity
• Excess bleeding during menstruation
 Need to quantify it
• “how many pads do you use?” “Is the blood clotting?”
4. Time
• How long does it last?
5. Setting
• Sitting on the couch or shoveling snow?
6. Aggravating or relieving factors
• Does the cold make it better? Does the warm? Does sitting down make it worse?
7. Associating factors
• Did you take Tylenol? How many?
8. Client’s perception of the symptoms
• Common symptoms are usually common diagnoses
• But don’t assume that every patient who comes in w/ chest pains is having a heart attack
• OLDCART
i. Onset
ii. Location
iii. Duration
iv. Contributing factors
v. Alleviating factors
vi. Radiation
vii. Timing

Front 28

Past Medical Health

Back 28

• General health
• Childhood illness
• Hospitalizations
• etc

Front 29

Current Health Status

Back 29

• Allergies
o Not just medications
o Also include reactions to exposures
o Ask if they are carrying an epipen
• Habits
o Former and current
• Does/did the patient smoke
 Include pack history
• 2 packs a day for 10 years=20 pack history
• Alcohol
 Drinks in a weeks time or a months time
• Can double what the patient tells you
o Want to quantify the exact amount of alcohol
o Past and present
• Drug Use
 Ask if they participated in any recreational drug use since college
o Diet
• Get a 24 hr recall
o Environmental Hazards
• Live near bus station, waste sites
o Use of safety measures
• Use of seatbelt, sunscreen, smoke detectors, etc.

Front 30

Social History

Back 30

• Some patients need money for cab fare to get to appointments→you need to know that!
• Home situation, religion, relationships, etc

Front 31

Family History

Back 31

• Can use a genogram
o MUST have a key
• Squares generally male, circles female
o MUST include history of major health issues family does NOT have
• Law states that if it is not included, it was not asked
 “Denies family history of…”
• ex) cancer, diabetes, altzeimers, glaucoma, etc

Front 32

Functional Assessment

Back 32

• ADLs=Activities of Daily Living
o Toileting, bathing, dressing, etc
• IADLs=Instrumental Activities of Daily Living
o Using telephone, preparing a meal, etc

Front 33

Review of Body Systems (ROS)

Back 33

• Ends history
• Summarizes
• Don’t have to ask every single one but most and enough to get a complete view about patient
o Ex) sore throat-ask about throat, lymph nodes, ears, nose…NOT questions about joint pain

Front 34

Ending the Health History

Back 34

• “After all of the questions that we just talked about, is there anything else you want to ask me today or you think that I should know?”
• …start physical examination

Front 35

Physical Assessment Techniques

Back 35

• In this order:
o Inspection
o Palpation
o Percussion
o Auscultation

• If abdomen→new order:
o Inspection
o Auscultation
o Percussion
o Palpation

Front 36

Inspection

Back 36

• Looking
• Yields the most physical signs

Front 37

Palpation

Back 37

• Sense of touch
• Purpose-confirm points noted in inspection
• Assess
o Temperature
o Vibrations-use boney side of hands to palpate
o Organ or masses location and size
• Diff parts of hands for diff factors
o Tips of fingers, dorsa hands, palmar
o Temp- use back of hand b/c skin is thinner and more able to detect warmth
• Light palpation-feel outside
• deeper palpation- inside organs and look for masses
o Enough pressure to see if patient facially displays discomfort

Front 38

Percussion

Back 38

• Strike finger to listen to sounds of air, masses, etc
• Particular sounds to look for
o Tympony-sound you should hear in stomach
• Air in stomach-good!
• Touch cheek
• Air in normal air-filled lungs
• Hyper ressonnance
 Abnormal-Too much air in lungs
• Someone w/ emphesema
• Dullness
• Over dense organs (ex. Liver)
• Over mass
• Flat
 Percuss over a big muscle or bone

Front 39

Auscultation

Back 39

• Listening w/ stethascope
• Sounds of organs (lungs, heart)
• Diaphram side-press hard
o High pitched sounds
• Bell-soft
o Low pitched sounds
o Ex) Blood pressure

Front 40

Assessment and Plan for H&P

Back 40

• Assessment
o final word on patient and diagnoses
• Plan
o Rx
o Dx-diagnostics
o Pt teaching
o Referalls
o Follow up

Front 41

Health Record Abbreviations

Back 41

• UTD=up to date
• HCM=health care maitenance
• NAD-no acute distress

Front 42

Episodic Visit Data Base

Back 42

• HPI includes history of when patient first developed symptoms
• Follows same template more focused on the disease
o -HEENT

Front 43

Follow Up Data Base

Back 43

• Include episodic history

Front 44

Height/Weight Measurement

Back 44

• Annual for adults
• Every time for children
o More important is the trend not a single measurement
• BMI (>25 at risk)
• Head circumference until 2

Front 45

Temperature Measurement Variations

Back 45

o Axillary temp lower than oral
o Tympanic slightly higher
o Rectal temp higher
o Record route
o Better to not use oral if the patient is unconscious, restless, cannot close mouth
o Temp lower in morning higher in evening
• Avg 37C or 98.6F

Front 46

Using a Thermometer

Back 46

• For oral
o Use glass or electric thermometer
o When glass
• Shake thermometer down to 35C/96F before using
• Once under tounge in closed mouth, wait 3-5 mins
• Read→reinsert for 1 min→read again
• Repeat until the temp stops rising
o electric
• digital readout takes about 10 seconds
o rectal
• under 2 months
• patient lies on one side
• insert lubricated rectal-specific thermometer in 3-4cm/1inch deep for 3 minutes
• insert lubricated electric thermometer for 10 seconds
o tympanic
• Over 2 months
• make sure external auditory canal is free of cerumen (which lowers temp)
• insert in canal 2-3 seconds
• measures core body temp which is higher than oral

Front 47

Heart Rate

Back 47

• Commonly use radial pulse
o If indicated, assess orthostatic
o Assess
• Rate normal for age group
• Tachycardia
• Bradychrdia
o Rhythm
o Force
o Elasticity
Normal <100

Front 48

Pediatric Heart Rate

Back 48

• Brachially up to age 4
• 1 full min rate in infants and young children bc of irregularities
• apical during sleep even better

Front 49

Respiration

Back 49

• Observe rate, rhythm, depth, and effort of breathing
o Count discretely so patient does not know
• Normal
o Infants 30-40
o Adult 12-20

Front 50

Pediatric Respiratory Rate

Back 50

• Count one full minute
• Need to detect rapid breathing (tachypnea)
• Newborns-diaphragmatic breathers

Front 51

Blood Pressure

Back 51

• Influences
o Age, weight, exercise, stress, etc
• Physiologic Factors controlling BP
o Peripheral vascular resistance and elasticity
• Volume and viscocity of blood
• Cardiac output
• Normal:
o Systolic 120-140
o Diastolic: <80
o Worse to have a high diastolic (100) than bigger difference btw systolic and diastolic

Front 52

Use of Sphygmomanometer

Back 52

• Choose correct cuff size
o Width of inflatable bladder should be 40% upper arm circumference (12-14cm in avg. adult)
o Length should be 80%
o Standard cuff 12x23 cm

Front 53

Optimal Conditions for BP

Back 53

• No smoking or drinking coffee 30 mins prior
• Quiet room
• Arm free of clothing
• Position arm so brachial artery is heart level

Front 54

Steps to Test BP

Back 54

• 1. Center bladder over brachial artery
o secure cuff snugly
o position patients arm slightly flexed at elbow
• 2. Estimate systolic pressure through palpation
o feel radial artery with fingers in one hand
o inflate cuff until you don’t feel the pulse anymore
o read measurement and add 30 mm Hg
• 3. Deflate cuff and wait 15-30 seconds
• 4. Place bell of stethoscope lightly over brachial artery
o make air seal w/ full rim
• 5. Inflate cuff rapidly to level needed
• 6. Deflate cuff slowly at rate 2-3 mm Hg/sec
• 7. Listen for the first 2 consecutive beats
o record this pressure as the systolic pressure
• 8. Continue to deflate until the sounds become muffled and disappear (usually a few mm Hg below muffling point)
o record the pressure of disappearance as the diastolic pressure
o Confirm the disappearance by dropping the pressure another 10-20
• 9. Deflate cuff rapidly to zero
• 10. Read systolic and diastolic levels to nearest 2 mm Hg
• 11. Wait 2 mins and repeat 1-10 and average 2 readings

Front 55

Older Adults-Trends in Vital Signs

Back 55

• BP-systolic hypertension with widened pulse pressure
• Heart rate and rhythm drop
o Pacemaker cells decline and affect reponse to physiologic stress
• Respiratory Rate unchanged
• Changes in temp and regulation→susceptibility to hypothermia

Front 56

Auscultatory Gap

Back 56

• Silent interval that may be present btw systolic and diastolic blood pressures
o Sound disappears for a while then reappears

Front 57

Orthostatic BP

Back 57

• Take serial BP and pulse measurements
• Take baseline while lying down
o Repeat with patient sitting and standing
• Perform when
o Suspected volume depletion
o Hypertensive or taking hypertensive meds
o Reports fainting
• Orthostatic hypotension
o Drop in systolic pressure more than 20 mm Hg and/or
o Pulse increase of 20 bpm or more changing positions

Front 58

General Survey History

Back 58

• Physical Appearance, mobility, body structure, behavior
• Questions
o Changes in weight
• Nutrition vs medical causes vs psycho-social
• Fatigue and weakness
o
• Fever, chills, night sweats
o Infection, inflammatory, etc

Front 59

Blood Pressure

Back 59

• Influences
o Age, weight, exercise, stress, etc
• Physiologic Factors controlling BP
o Peripheral vascular resistance and elasticity
• Volume and viscocity of blood
• Cardiac output
• Normal:
o Systolic 120-140
o Diastolic: <80
o Worse to have a high diastolic (100) than bigger difference btw systolic and diastolic

Front 60

Use of Sphygmomanometer

Back 60

• Choose correct cuff size
o Width of inflatable bladder should be 40% upper arm circumference (12-14cm in avg. adult)
o Length should be 80%
o Standard cuff 12x23 cm

Front 61

Optimal Conditions for BP

Back 61

• No smoking or drinking coffee 30 mins prior
• Quiet room
• Arm free of clothing
• Position arm so brachial artery is heart level

Front 62

Steps to Test BP

Back 62

• 1. Center bladder over brachial artery
o secure cuff snugly
o position patients arm slightly flexed at elbow
• 2. Estimate systolic pressure through palpation
o feel radial artery with fingers in one hand
o inflate cuff until you don’t feel the pulse anymore
o read measurement and add 30 mm Hg
• 3. Deflate cuff and wait 15-30 seconds
• 4. Place bell of stethoscope lightly over brachial artery
o make air seal w/ full rim
• 5. Inflate cuff rapidly to level needed
• 6. Deflate cuff slowly at rate 2-3 mm Hg/sec
• 7. Listen for the first 2 consecutive beats
o record this pressure as the systolic pressure
• 8. Continue to deflate until the sounds become muffled and disappear (usually a few mm Hg below muffling point)
o record the pressure of disappearance as the diastolic pressure
o Confirm the disappearance by dropping the pressure another 10-20
• 9. Deflate cuff rapidly to zero
• 10. Read systolic and diastolic levels to nearest 2 mm Hg
• 11. Wait 2 mins and repeat 1-10 and average 2 readings

Front 63

Older Adults-Trends in Vital Signs

Back 63

• BP-systolic hypertension with widened pulse pressure
• Heart rate and rhythm drop
o Pacemaker cells decline and affect reponse to physiologic stress
• Respiratory Rate unchanged
• Changes in temp and regulation→susceptibility to hypothermia

Front 64

Auscultatory Gap

Back 64

• Silent interval that may be present btw systolic and diastolic blood pressures
o Sound disappears for a while then reappears

Front 65

Orthostatic BP

Back 65

• Take serial BP and pulse measurements
• Take baseline while lying down
o Repeat with patient sitting and standing
• Perform when
o Suspected volume depletion
o Hypertensive or taking hypertensive meds
o Reports fainting
• Orthostatic hypotension
o Drop in systolic pressure more than 20 mm Hg and/or
o Pulse increase of 20 bpm or more changing positions

Front 66

General Survey History

Back 66

• Physical Appearance, mobility, body structure, behavior
• Questions
o Changes in weight
• Nutrition vs medical causes vs psycho-social
• Fatigue and weakness
o
• Fever, chills, night sweats
o Infection, inflammatory, etc