PYSICAL

EXAMINATION
HEALTH
ASSESSMENT
ANNA BYILINGIRO MBANGUKIRA

LPN, RN, BSN, MSN

Purpose and Goals of Health
History and Interview
The health history and physical exam are essential and core to
the diagnostic and treatment process. We develop a
partnership with the patient that leads to shared, individualized
goals and treatments.

 Establish rapport and trust

 Gather subjective data regarding health issues, problems
and concerns
 Explore past and present factors which contribute to
current health condition
 Provide information to help establish a diagnosis and initial
plan of care
 Provide a framework for an accurate physical exam
 Allow opportunity for sharing of information and health
counseling
Types of Health Histories

 Complete :
 Used for new patient or one who has not been seen for a long
time
 Problem or focused:
 Used when a new problem develops and the reason for the
visit is specific
 Follow-up visit:
 Is specifically set up to check on the progress of treatment or
to review labs that were drawn, etc
Requirements for a successful
interview
 Establish rapport---be friendly,
respectful and relaxed, use patient
name.
 Use appropriate eye contact and
keep culturally sensitive regarding
touch and personal space.
 Provide privacy, confidentiality
and a comfortable environment.
 Use appropriate communication
skills, eg. Open-ended questions,
rephrasing and using periods of
silence to elicit details and
subjective data.
Successful
Interview, cont.
 Be sensitive and empathetic
 Be careful when dealing with the patient who
demonstrates anger, depression, or manipulative
behavior
 Share personal information briefly when asked, and
return the conversation back to the patient situation
 For elderly patients--- be aware of visual and hearing
impairments---speak clearly and use good eye
contact, if appropriate for culture. Be aware of
possible memory loss or cognitive impairment
 For children---pay attention to them, play with them
and observe for clues of family dynamics.
 For teenagers---show them respect and recognize
need for confidentiality. Let them know you are their
advocate. Don’t force conversation
 For patients with disabilities---adapt interview to
meet their needs and involve them as much as
possible
Steps to Obtain the
Health History
 Ask about the chief complaint (CC)—reason for the visit
 History of the present illness (HPI)
 Past medical and surgical history
 Family health history
 Social history and personal health habits and religious
preference
 Review of body systems (ROS)
Obtaining a health history:
a systematic approach
 Arrange the setting, if possible, to
provide comfort for all parties involved,
providing privacy, good lighting, in a
quiet, uninterrupted setting.
 Ideally, no barriers, e.g.. desks, beds,
etc. should separate patient from
interviewer. Un-obtrussive access to a
clock is also necessary to facilitate time
management.
 Collect basic patient information—
identifying data
 Name, age, etc

 Determine the chief complaint (CC)

 Find out why the patient has come

to seek medical care today---in

patient’s own words
 Take notes sparingly

 Avoid medical jargon and leading

questions
 Start with open-ended questions

then proceed with more direct ones

 Obtain a history of the present illness

 “How long has this been a Problem” or

 “When did these symptoms first begin?”)
 Explore the following: (OLD CART)
 Onset
 Location
 Duration
 Contributing factors
 Accompanying symptoms
 Relieving factors
 Treatments tried and their affects
Also ask about:
 Health state before present problem
 Affect of illness on quality of life (QOL), or lifestyle
 How patient is dealing with the changes and who and
what are their source of strength and support
Obtain the past medical and surgical
history

 Often filled out by patient on a check sheet

 Past and current medications
 Allergies to meds, foods or environmental factors
 Transfusions in the past?
 General health
 Childhood and adult illnesses
 Immunizations—past and current
 Surgeries---reason, dates, any complications, etc
 Serious injuries and any resulting disabilities
 Emotional status
 Functional limitations
Obtain the family health history
 Often filled out by questionnaire
 Use of genogram ideal but not
practical
 Genogram includes age and
health status of each family
member, along with diseases and
cause of death---any family
pattern and risk of disease is
noted
 Any family member with illness
similar to patient’s current
complaints?
 Any hereditary disorders?
 History of major diseases---
diabetes, hypertension, CAD,
stroke, breast cancer, ovarian
 If sensitive issues arise, be matter of
fact, don’t preach or apologize
 sexual preference
 alcohol, tobacco, caffeine or drug use
(CAGE or other questionnaire as
appropriate)
 Exercise and relaxation
 religious preference and practices
 Occupation home conditions, etc.
 Obtaining the personal, wellness and
social history personal habits)
Conduct a review of body systems (ROS)

 Inquire about general

constitutional symptoms,
eg.
 Chills
 Fever
 Malaise
 Fatigability
 Night sweats
 Weight changes
 Diet
ROS, cont.
 Skin, hair and nails
 Head, neck, eyes, ears, nose, mouth and
throat
 Chest, lungs and breathing
 Heart and blood vessels
 Stomach and bowels
 Neuromuscular
 Musculoskeletal
 Genitourinary
 Psycho/social/mental
Conclude the health history
 Clarifyand summarize
 Ask the following
questions:
 Is there anything else that you think I should
know?
 What problem concerns you the most?
 What do you think is the matter with you?
 What worries you the most about how you
are feeling?
 What are your goals for this encounter?
(need to be mutually negotiated)
 Relief of symptoms
 Reassurance that symptoms are not
reflective of a serious condition
 Knowledge and information, etc.
For pediatric patients

Need to get
information
regarding
pregnancy,
gestation,
eating habits,
school
concerns,
behavioral
issues, etc.
Formulating the hypothesis

 Before beginning the physical exam, the health

care practitioner should already have in mind
what the most probable differential diagnoses
are.
 The exam may or may not add further
information to that “huntch”.
 The more experienced the practitioner is, the
more quickly and accurately they will formulate
their hypothesis.
 Hypothesis is based on clinicians knowledge and
expertise of patho, and presenting S & S----but
also on patient’s age, gender, race, risk factors
and probabilities.
Differential Diagnoses
A list of the possible diagnoses is made
following the health history
To “rule-in” a probable diagnosis the clinician
would need to know the diagnostic criteria
and which diagnostic tests and physical exam
findings would help to confirm it
To “rule out” a diagnosis, eg. R/O MI, the
same is true---except the diagnostic criteria
would not be present---eg?????
“Gold” standard” diagnostic tests would be
used to help in this diagnostic process,
eg.????
Beginning the Physical
Examination: General Survey
 Facial expression
 Mobility
 Dress
 Posture
 Speech pattern
 Stature
 Eye contact
 Orientation
 Odor
 Nutritional status
 Assessment Tools

 Cotton balls  Scale with height

 measurement
Gloves
 Skin calipers
 Metric ruler (Clear)
 Specula
 Near vision and visual acuity
charts  Sphygmomanometer
 Ophthalmoscope  Stethoscope
 Otoscope  Tape measure
 Penlight  Thermometer
 Percussion hammer  Tuning fork
 Wooden tongue blade  Watch or clock with second
hand
 Mental status exam
 Ifgeneral survey
indicates abnormality in
affect or mental
condition, then proceed
with further mental
testing.
 Include assessing
alertness to person,
place and time
 Assess for depression
 Use of Mini-Mental State
Exam for anyone
suspected of a
decreased mental
status.
 Vital Signs and
Anthropometric
 Respirations
 Pulse
Measurements
 Temperature
 Blood pressure
 Height and weight
 BMI or body fat %
 Waist/hip ratio
 Skin fold thickness
Techniques of examination

Inspection
Palpation

- Light
- Deep
- bimanual
Percussion
 Direct
 Indirect
 Blunt

Auscultation
 Inspection

 Beginswith first
contact
 Critical observation
 Systematic and
deliberate
 Good lighting
 Adequate exposure
Inspection
 Compare sides
 Palpation

 Usehands and
fingers
 Non painful areas
first
 Encourage
relaxation
 Warm hands and
short fingernails
 Useof universal
precautions
 Information Gained
from Palpation
 Texture
 Temperature
 Moisture
 Turgor
 Size and shape of body part
 Rhythm or amplitude
 Symmetry
 Tenderness
 Masses or lumps
 Parts of hands used for
palpation
 Finger tips
 Pulses with 3rd and 4th fingertips
 Finger
and thumb
opposition
 lesions
 Dorsal (back of hands)
 temperature
 Palmar/ulnar
 vibrations
 Palpation Methods
 Light: (1-2cm) for
assessing temp., texture,
moisture, tenderness,
pulses, vibrations, pain,
lesions, etc
 Deep: (3-4cm) for assessing
abdominal structures,
especially the liver
 Bimanual: use of both
hands to assess the texture
and firmness of an organ
 Capture/envelope
 Kidney
 Thyroid
 Uterus and ovaries
 Etc
 Percussion
 Most challenging PE skill
 Involves striking patient’s
skin surface with fingers or
hands to elicit sounds,
evaluate reflexes, uncover
abnormal masses, and
detect pain or tenderness
 Nurses seldom use this
technique while assessing
the hospitalized patient but
may be used in outpatient
setting
 3 Basic Percussion

Techniques
Direct :
 tap directly on patient’s
skin. Use short, sharp
strokes of the fingertips of
dominant hand. Best for
percussing paranasal
sinuses.
 Indirect:
 Place pad of 3rd finger of
non-dominant hand over
area to be assessed. Use
dominant hand to strike
above or below
interphalangeal joint. (chest,
abdomen)
 Blunt Percussion:
 Strike ulnar
surface of fist
against patient’s
skin surface or
place non-
dominant hand
over the area and
strike over it.
Used mainly to
detect
inflammation or
pain (kidney—CVA
tenderness)
Auscultation
 Listening to sounds produced by
internal body structures
 Usually follows inspection, palpation
and percussion, except when
examining the abdomen---then we
listen after inspection and before
palpation or percussion (this can alter
normal sounds)
 Usually involves:
 Heart
 Lungs
 Blood vessels
 bowels
Tips for Successful Auscultation
 Eliminate noises around you
 Listen over bare skin if possible
 Use warm stethoscope
 Wet a hairy chest to avoid crackles
 Listen for presence or absence of
sounds, as well as quality
 Use bell of stethoscope for low-
pitched sounds (abnormal heart
and vascular)
 Use diaphragm for all other body
sounds which are high-pitched
sounds
Understanding Examination Equipment

 Stethoscope
 Ear pieces should angle forward
 Use diaphragm to detect high-pitched sounds,
eg. Heart, lung and bowel
 Use bell to best hear soft, low-pitched sounds,
eg. Heart murmurs and gallops
 Thermometers
 Glass mercury
 Electronic
 Tympanic membrane
 Many other methods
 Sphygmomanometer
 Mercury
 Aneroid
 automatic
 Otoscope
 Used to visualize ear canal and tympanic
membrane
 Disposable ear speculums

 Ophthalmoscope
 Used to examine internal eye structures
 Has a light source with lenses and mirrors—
has a base (with batteries) and a head
which includes:
 Viewing window
 Apertures and aperture selector dial
(changes width of light beam)
 Lens selector dial (changes the lens to
bring objects into focus
 Lens indicator (displays lens
magnification power---from 0 to +40 or
from 0 to -20)

 Pulse oximeter
 Photo electric device which measures
arterial oxygen saturation at the capillary
level (non-invasive)
The Rest of the Physical Exam
 Following the General survey, each
body system will be assessed
systematically and with special detail
to the areas noted in the health
history, ROS and the chief complaint
 Head and neck (including eyes,
ears, nose, mouth, sinuses, and
cranial nerves
 Chest and back, including
respiratory system, heart and
breasts
 Abdomen and genitals
 Integumentary (skin, hair and
nails)
 Musculoskeletal and neurological
systems
Documentation Tips

 Record the chief complaint accurately.

 Include ample detail without rambling
 Be objective, specific, and quantitative.
 Include significant positives as well as
significant negatives (what was not found
that may help to R/O some of the
differentials).
 Document findings promptly, indicating
possible differentials and what tests will be
ordered to “rule them out”.
 Write neatly and legibly.
 Use appropriate abbreviations.
 Subjective----
SOAP charting
 Chief complaint and history of the present problem
 Objective----
 Findings in the physical exam
 Diagnostic study results
 Assessment----
 Conclusion of the above complaints and findings---
 May be several possible differentials with rationale on why they have
been selected
 May be a cluster of symptoms without a definite conclusion
 Plan----
 What further diagnostics will be ordered
 What management will be initiated
 What education will be done
 When to return for further F/U, to review diagnostic tests and
effectiveness of management, etc
 At times the diagnosis is only evident after a treatment fails or is successful
 Inductive clinical reasoning is often used to come to diagnostic conclusions

 Remember---if it looks like a duck, sounds like a duck, and walks like a
duck---it probably is a duck!!!

 If it sounds like the thundering hoofs of a horse, it is most likely a horse

and not a zebra—(unless you are in Africa!!)-but never completely R/O the
zebra if it is not really clear!!
 SAFETY MEASURES
CONSIDERED IN HEALTH
ASSESSMENT
 Patient safety is an essential part of nursing care that aims to prevent avoidable errors and patient harm. Patient safety is a feature of a healthcare system and a set of tested ways for improving care.
 The hazards of nursing work can impair health both
acutely and in the long term. These health outcomes
include musculoskeletal injuries/disorders, other injuries,
infections, changes in mental health, and in the longer
term, cardiovascular, metabolic, and neoplastic diseases.
 Of all the members of the health care team, nurses
therefore play a critically important role in ensuring
patient safety by monitoring patients for clinical
deterioration, detecting errors and near misses,
understanding care processes and weaknesses inherent
in some systems, and performing countless other tasks to
...
 Errors, Injuries, Accidents, Infections. In some hospitals, patient
safety is a top priority. Strong health care teams reduce
infection rates, put checks in place to prevent mistakes, and
ensure strong lines of communication between hospital staff,
patients, and families.
 The Patient Safety and Quality Improvement Final
Rule (Patient Safety Rule) establishes a framework
by which hospitals, doctors, and other health care
providers may voluntarily report information to
Patient Safety Organizations (PSOs), on a privileged
and confidential basis, for the aggregation and
analysis of patient ...
 It will be important for all of society to work to
improve communication between direct care nurses
and nursing management and administration,
promote staffing flexibility and utilization of
appropriate staffing formulas, discourage the use of
mandatory overtime, provide adequate compensation,
minimize hazards, promote.
CLINICAL REASONING IN
THE ASSESSMENT OF
CLIENTS
 Clinical reasoning, also known as clinical judgment,
is the process by which clinicians collect signs,
process information, understand the patient's medical
situation or problem, plan and implement appropriate
medical interventions, evaluate outcomes, and learn
from this entire process
 Nursing literature on clinical reasoning and
decision-making. In simple terms,
reasoning is defined as the power of the mind
to think and understand in a logical way in
order to form a conclusion or judgement
 Clinical reasoning is defined in practice-based disciplines as
the application of critical thinking to the clinical situation. ...
Clinical reasoning refers to a set of cognitive processes used to
discern the relevance of the evidence and scientific knowledge as
it applies to a particular patient.
 Clinical reasoning The process by which nurses (and other
clinicians) collect cues, process the information, come to an
understanding of a patient problem or situation, plan and
implement interventions, evaluate outcomes, and reflect on and
learn from the process.