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INTRODUCTION TOHEALTH ASSESSMENT
NUR123 Spring 2009
K. Burger, MSEd, MSN, RN, CNE
PPP by: Victoria Siegel RN, CNS, MSNSharon Niggemeier RN, MSNRevised by: Kathleen Burger
TECHNIQUES OF PHYSICAL ASSESSMENT
GENERAL SURVEY
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Health Assessment
Is holisticdata collection ANDanalysis
Utilizes the nursing process
Incorporates critical thinking.
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Health Assessment
Includes knowledge of developmentalstages throughout the life cycle
Includes physical,mental,psychosocialassessment along with assessment for
domestic violence, elder abuse andchild abuse
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Health Assessment:The Health History
Begins with reason for seeking care(chief complaint is previously used term)
& health history Document using the patients own
words
Elicit a complete description frompatient
Document duration of complaint
What aggravates condition, what
may alleviate it?
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Types of Health Histories
Complete
Interval
Problem focused or chiefcomplaint
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History Taking
Well developed interview skills andcareful documentation
Environment conducive to privacyand comfort
Is the client a good historian?
Reasons for seeking health care Interview- intro, working,
termination phases
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Complete Health History
Biographical
Reason for seeking
health care Present
health/Illness
Past health
Family health
Review of systems
Psychological
FunctionalAssessment
Perception of
health
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Present Health/IllnessReason for seeking care
Onset, duration, precipitatingfactors.
Frequency, duration Associated symptoms i.e. N/V
Alleviating/ aggravating factors
ROS re: CC
Relevant family, occupational orrecreational history.
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Past Health History
Past general health
Childhood illnesses
Accidents/ injuries
Hospitalizations/surgeries
Acute and chronic illnesses
Immunizations
Allergies, medications, transfusions
Obstetric History
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Current Health
Habits
Meds (includingOTC/Herbal/Vitamins)
ExerciseSleep
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Family History
Important to know to determinerisks
Status of family membersParents, siblings, grandparents
Status of spouse/significantother and Children
Construct Genogram
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Review of Systems: ROS
Review past and presenthealth status of each bodysystem.
Review health maintenance.
A Head-to- Toe approach
May elicit new information
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Psychological Function
Cognitive memory,comprehension
Response to illness andhealth
Psych history, meds,anxiety?
Cultural considerations
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Functional Assessment
ADLs
Sleep/rest
Nutrition/problems with diet,weight
Alcohol /Substance abuse
Smoking history (in pack years)
Coping difficulties
Domestic/ child abuse
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Perception of Health
How one defines health
Views on ones health statusWhat are ones expectationspertaining to health and
health care
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Physical Examination (PE)
Goal is to identify variations
from normal.Explain procedure first
Head to Toe
Unaffected areas before affected
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Techniques of PE
Four components used in specificorder:
Inspection
Palpation
PercussionAuscultation
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Techniques of PE
Inspection- First techniques used.What examiner sees, hears and
smells. Observe symmetry.
Palpation- Second technique using
fingers and hands to touch. Lightpalpation first then deep palpation
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Techniques of PE
Percussion- Third techniquetapping onskin surface which creates a vibration ofunderlying structures. The vibration
produces a sound, may aid in diagnosis. Resonant- normal lung.
Hyperresonant- Childs lung oremphysema.
Tympany- Air filled organ, e.g., stomachor intestine.
Dull- Dense organ, e.g., liver or spleen.
Flat- No air present, e.g., bone.
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Techniques of PE
Uses for Percussion: Mapping outlocation and size of an organ
Determining density (air, fluid, solid) ofa structure
Detecting superficial mass (up to 5 cmdeep)
Eliciting pain if underlying structure isinflamed
Eliciting a DTR using a percussion
hammer
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Techniques of PE
Auscultation-Usually last techniqueduring PE (*exception abdomen,
its the 2
nd
technique afterinspection)
Use stethoscope to block sounds notmagnify
Diaphragm-firmly against skin
Bell- lightly against skin
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Auscultation
Description of sounds heard
Pitch- frequency of sound vibrations,
high or low. Intensity- loudness of sound: loud or
soft (amplitude)
Duration- length of sound: short, long
Quality- subjective terms- harsh,tinkling, etc
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Physical Exam
Utilize 4 techniques
Proper settingEquipment
Clean/ safe environment
Remember client comfort
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Summary
Health assessment
includes:Complete health history
ROSPhysical Exam
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General Survey
Study of the whole individual
Overall impression
Begins at the first encounter with aperson
Introduction to the physical
assessment Composed of 4 parts: physical
appearance, body structure, mobility
& behavior
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General Survey Physical
Appearance
Age Sex
LOC
Skin color Facial features
Body Structure
Stature
Nutrition Symmetry
Posture
Position Body contour
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General Survey
Mobility
Gait
Range of
Motion (PROMor AROM)
Behavior
Facialexpression
MoodSpeech
Dress/Hygiene
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General Survey
Includes Height & Weight
Vital signs: Temperature, Pulse,Respiration & Blood Pressure
Recognize transcultural
considerationsNote S/S (signs/symptoms) of
distress/pain
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AssessingDistress/Pain
Assessment includes:
S- SeverityL- Location
I- Influencing factors
D- Duration
A- Associated Symptoms
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Assessing Distress/Pain
Pain assessment = 5thvital sign
Utilize pain scale
Understand chronic vs acutepain
Recognize gender, transculturaland developmental factorseffecting pain