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Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Health History and Physical Assessment Lecture 1.

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Presentation on theme: "Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Health History and Physical Assessment Lecture 1."— Presentation transcript:

1 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Health History and Physical Assessment Lecture 1

2 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

3 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Health History Physical Assessment Subjective database Obtained through interview Use of effective communications skills Objective database Obtained by observation and physical assessment techniques Completes the client’s health picture

4 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Historical information often comes from a variety of sources, including The patient The family Friends Other observers

5 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

6 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Biographical Data Name: Age: Gender: Marital status: Occupation:

7 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

8 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Analysis of the Symptom What What makes symptomsbetter/worse? DescribeWhat does pain feel like? Where Where & where does pain go? How On Scale of 1-10 (other scales) WhenWhen, How often, How long?

9 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

10 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

11 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

12 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Review of Systems Inquires about signs and symptoms as well as diseases related to each body system

13 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Physical assessment

14 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Physical Assessment Usually performed after the health history Examiner must wash hands Make the patient comfortable Assessment must be systematic and organized Head – to - Toe Assessment Assessment Sequencing

15 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment techniques Inspection Palpation Percussion Auscultation

16 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

17 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

18 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment techniques - Cont. Percussion Technique that translates the application of physical force into sound Assess underlying structures for location, size, density of underlying tissue.

19 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Percussion Technique

20 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Percussion Sounds Gastric bubbleTympany Emphysematous lungHyperresonance Healthy lungResonance LiverDullness MuscleFlattness

21 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

22 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Nutritional Assessment BMI Dietary data –Food record –24-hour recall –Diet diary Conducting the Dietary Interview Cultural and religious considerations

23 Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 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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